American Medical Student Association American Medical Student Association (AMSA) End of Life (EOL) Education (AMSA) End of Life (EOL) Education Initiative Project in-a-Box (PIB)Initiative Project in-a-Box (PIB)

Richard J. LinRichard J. Lin

Harvard Medical SchoolHarvard Medical School

August 1, 2003August 1, 2003

Chicago, ILChicago, IL

An Experiential Learning An Experiential Learning Module of EOL CareModule of EOL Care

Overview of current EOL curriculumOverview of current EOL curriculum Development of an experiential EOL Development of an experiential EOL

learning module - The EOL Care learning module - The EOL Care Mentorship ProgramMentorship Program

Program evaluation and assessmentProgram evaluation and assessment Finance, portability, and future Finance, portability, and future

integration into the core curriculumintegration into the core curriculum

HMS EOL Curriculum OverviewHMS EOL Curriculum Overview

Lack of EOL Component in the Lack of EOL Component in the Current Core CurriculumCurrent Core Curriculum

MSI and MSII - Popular elective “Living MSI and MSII - Popular elective “Living with Life-threatening Illness”with Life-threatening Illness”

MSIV - Two elective rotations in Pain, MSIV - Two elective rotations in Pain, Palliative medicine, and Psychosocial Palliative medicine, and Psychosocial OncologyOncology

Residents and Physicians - Elective Residents and Physicians - Elective palliative care rotations and fellowship; palliative care rotations and fellowship; faculty development seminarfaculty development seminar

Living With Life-threatening Living With Life-threatening Illness (LWLTI) CourseIllness (LWLTI) Course

Developed by two palliative care experts at HMS, Developed by two palliative care experts at HMS, Drs. Susan Block (DFCI) and Andrew Billings Drs. Susan Block (DFCI) and Andrew Billings (MGH)(MGH)

Course formats are lecture; small group Course formats are lecture; small group discussion/reflection; case conference; role discussion/reflection; case conference; role plays; and individual patient visitsplays; and individual patient visits

Covers the basics of hospice and palliative Covers the basics of hospice and palliative medicine: death and dying process; advanced medicine: death and dying process; advanced care planning; pain control and symptom care planning; pain control and symptom management; physician roles; ethical, cultural management; physician roles; ethical, cultural and spiritual issues and spiritual issues

Informational and Experiential Informational and Experiential Gaps in LWLTIGaps in LWLTI

25 to 30 students enroll each year, accounts for 25 to 30 students enroll each year, accounts for only 7 to 8 percent of the student bodyonly 7 to 8 percent of the student body

Focus more on integration of palliative care into Focus more on integration of palliative care into mainstream medicine and less on utilizing hospice mainstream medicine and less on utilizing hospice care for dying patientscare for dying patients

Most participating patients are in the gray zone Most participating patients are in the gray zone with prominent medical issueswith prominent medical issues

Emphasizes physician leadership, no exposure to Emphasizes physician leadership, no exposure to interdisciplinary team workinterdisciplinary team work

PBL cases are not integrated with patho-PBL cases are not integrated with patho-physiology and clinical medicinephysiology and clinical medicine

The EOL Care Mentorship ProgramThe EOL Care Mentorship Program

Goals and ObjectivesGoals and Objectives

Introduction of the key concepts of Introduction of the key concepts of hospice and palliative medicinehospice and palliative medicine

Experiential learning of EOL care Experiential learning of EOL care through interdisciplinary team workthrough interdisciplinary team work

Cultivation of student interest in EOL Cultivation of student interest in EOL care and palliative medicinecare and palliative medicine

Advocacy of integration of EOL Advocacy of integration of EOL component into the core curriculumcomponent into the core curriculum

The EOL Care Mentorship ProgramThe EOL Care Mentorship Program

Forming partnerships with local hospice and Forming partnerships with local hospice and hospital-based palliative care teams hospital-based palliative care teams

Drawing the enthusiasm and expertise of a Drawing the enthusiasm and expertise of a large number of faculty members who has an large number of faculty members who has an interest in EOL careinterest in EOL care

Targeting mostly first and second year Targeting mostly first and second year medical studentsmedical students

Assigning two or three students to each Assigning two or three students to each hospice/palliative care team; potentially hospice/palliative care team; potentially serving as volunteersserving as volunteers

Potential Partner I : Potential Partner I : Healthcare Dimensions HospiceHealthcare Dimensions Hospice

A subsidiary of Dana-Farber Cancer Institute A subsidiary of Dana-Farber Cancer Institute (DFCI) and Partners Healthcare System(DFCI) and Partners Healthcare System

Serving all 37 counties in the greater Boston Serving all 37 counties in the greater Boston area, currently has 150 patientsarea, currently has 150 patients

Comprehensive hospice service for both Comprehensive hospice service for both adults and childrenadults and children

Non-for-profit, Medicare and Medicaid Non-for-profit, Medicare and Medicaid certified, JACHO accreditedcertified, JACHO accredited

Medical Director and full-time physicians, Medical Director and full-time physicians, PCP participation is highPCP participation is high

Potential Partner II : Potential Partner II : Pain and Palliative Care ProgramPain and Palliative Care Program

Based in DFCI and Brigham and Women’s Based in DFCI and Brigham and Women’s Hospital (BWH)Hospital (BWH)

Serving mostly cancer patientsServing mostly cancer patients Work alongside of the medical team to Work alongside of the medical team to

integrate palliative care into comprehensive integrate palliative care into comprehensive plan of care plan of care

Interdisciplinary team approach for pain and Interdisciplinary team approach for pain and symptom control and psychosocial supportsymptom control and psychosocial support

Physician leadership with Dr. Janet Abrahm Physician leadership with Dr. Janet Abrahm (Medical Oncologist)(Medical Oncologist)

Potential Partner III : Potential Partner III : Palliative/Supportive Medicine TeamPalliative/Supportive Medicine Team

Based in Harvard Vanguard Medical Based in Harvard Vanguard Medical Associate, a community healthcare networkAssociate, a community healthcare network

Serving community hospitals, nursing homes, Serving community hospitals, nursing homes, and extended care facilities, predominately and extended care facilities, predominately serving geriatric populationserving geriatric population

Consultative services on pain and symptom Consultative services on pain and symptom management and psychosocial supportmanagement and psychosocial support

Physician leadership with Dr. Robert Physician leadership with Dr. Robert Buxbaum (Internist and Geriatrician)Buxbaum (Internist and Geriatrician)

Potential Partner IV : Potential Partner IV : Pediatric Advanced Care TeamPediatric Advanced Care Team

Based in Children’s Hospital and DFCIBased in Children’s Hospital and DFCI Serving children with advanced illnessServing children with advanced illness Support medical treatment for underlying Support medical treatment for underlying

illness while provide optimal quality of lifeillness while provide optimal quality of life Using a family-centered approachUsing a family-centered approach Extensive grieving and bereavement support Extensive grieving and bereavement support

for parentsfor parents Physician leadership with Dr. Joanne Wolfe Physician leadership with Dr. Joanne Wolfe

(Pediatric Oncologist)(Pediatric Oncologist)

Some Possible Activities of the Some Possible Activities of the EOL Care Mentorship ProgramEOL Care Mentorship Program

Home visits with physicians, nurses, Home visits with physicians, nurses, social workers, and chaplainssocial workers, and chaplains

Nursing home visitsNursing home visits Hospital inpatient palliative care roundsHospital inpatient palliative care rounds IDG meetingIDG meeting Clinical case conferenceClinical case conference Small group reflection/discussionSmall group reflection/discussion

Logistic Considerations of the Logistic Considerations of the EOL Care Mentorship ProgramEOL Care Mentorship Program

Student time commitmentStudent time commitment Faculty time commitment and Faculty time commitment and

willingness to teach and supervisewillingness to teach and supervise Patient wishes and confidentialityPatient wishes and confidentiality Logistic arrangement with the hospice Logistic arrangement with the hospice

and the palliative care teamand the palliative care team Longitudinal program vs intensive Longitudinal program vs intensive

clinical rotationsclinical rotations

Program Assessment and EvaluationProgram Assessment and Evaluation

Participant EvaluationParticipant Evaluation

Pre- and post-test/questionnairePre- and post-test/questionnaire Preceptor evaluationPreceptor evaluation Home visit experience write-upsHome visit experience write-ups Illness history/treatment/prognosisIllness history/treatment/prognosis Pain and symptom managementPain and symptom management Psychosocial and spiritual distressPsychosocial and spiritual distress Patient wishes and family/caregiver concernsPatient wishes and family/caregiver concerns Patient-doctor communication and relationshipPatient-doctor communication and relationship Student learning experienceStudent learning experience

Program AssessmentProgram Assessment

Participant feedback and suggestionParticipant feedback and suggestion Faculty/hospice reviewsFaculty/hospice reviews Patient/family surveysPatient/family surveys Assessment by mentors and the Assessment by mentors and the

curriculum committeecurriculum committee

MiscellaneousMiscellaneous

Program FinanceProgram Finance

Potential exists for an elective, paid student Potential exists for an elective, paid student fellowship program fellowship program

AMSA seed grant for EOL Education Initiative AMSA seed grant for EOL Education Initiative Project-in-a BoxProject-in-a Box

HMS Community Service Program at the HMS Community Service Program at the Office of Enrichment ProgramsOffice of Enrichment Programs

HMS Student Council (student interest group)HMS Student Council (student interest group) HMS Center for Palliative CareHMS Center for Palliative Care The Neil Samuel Ghiso Foundation (NSGF)The Neil Samuel Ghiso Foundation (NSGF)

The Neil Samuel Ghiso FoundationThe Neil Samuel Ghiso FoundationFor Compassionate Medical CareFor Compassionate Medical Care

Mission The Neil Samuel Ghiso Foundation is dedicated to fostering compassionate care for chronically and terminally ill patients and their families through medical education and training.

Activities This year NSGF initiated its first program, the Neil Ghiso Fellowship, awarding grants to two Harvard medical students to work with palliative care teams in the treatment of chronically and terminally ill patients. In addition to caring for patients, the fellows will conduct research relating to compassionate care and, at the conclusion of the project, will submit papers reflecting on their experiences and sharing their findings. Over time NSGF plans to expand this program to other medical schools.

Program PortabilityProgram Portability

Stand alone programStand alone program Integration into the elective LWLTI courseIntegration into the elective LWLTI course Integration into the HMS Primary Care Integration into the HMS Primary Care

Mentorship ProgramMentorship Program Expansion and Integration into the Death and Expansion and Integration into the Death and

Dying Student Interest GroupDying Student Interest Group Integration into the core curriculum (ICM and Integration into the core curriculum (ICM and

Patient-Doctor courses)Patient-Doctor courses) Adaptable to other medical schools Adaptable to other medical schools

Program ShortcomingsProgram Shortcomings

Elective in nature Elective in nature In program pilot years it may be able to take In program pilot years it may be able to take

only 4 to 8 studentsonly 4 to 8 students Designed mainly for students with advanced Designed mainly for students with advanced

knowledge/interest/experienceknowledge/interest/experience Lacking an organized didactic componentLacking an organized didactic component Time commitment and travelTime commitment and travel May not be able to follow the same patient May not be able to follow the same patient

over time due to logisticsover time due to logistics

What I have LearnedWhat I have Learned

To Cure SometimesTo Cure Sometimes

To Relieve OftenTo Relieve Often

To Comfort AlwaysTo Comfort Always

-16-16thth century anonymous century anonymous

Thank You So Much !!!Thank You So Much !!!

Horizon HospiceHorizon Hospice Dr. Mike MarschkeDr. Mike Marschke Dr. Mike PreodorDr. Mike Preodor Lori HedgesLori HedgesHospice of IllinoisHospice of Illinois Schuyler Schuyler CunninghamCunningham Jackie JohnsonJackie Johnson Joanne MurrayJoanne Murray

AMSA FoundationAMSA Foundation

Fellow EOL Interns:Fellow EOL Interns:

Angie, Andy, Ashley, Angie, Andy, Ashley, Elizabeth, Erin, Donna, Elizabeth, Erin, Donna, Hamayun, Heather, Hamayun, Heather, Jim, Mabel, Melanie, Jim, Mabel, Melanie, and Munishand Munish