Access to palliative medicine training for Canadian family medicine residents.

An International Survey of Undergraduate Medical Education in Palliative Medicine

98 Background: The ACGME requires incorporating palliative care (PC) competencies into Hematology and Medical Oncology (HMO) fellowship curriculum. The primary aim of this study was to determine the attitudes and beliefs regarding PC of HMO fellows who completed a 4 week mandatory PC rotation. Methods: The rotation included a 4 week standardized curriculum covering all PC domains and all HMO fellows rotated in acute palliative care unit (APCU), consult service and outpatient clinic. HMO fellows were provided educational materials and attended all didactic sessions. All HMO fellows from 2004 to 2017 were sent a 39 item survey adapted from published studies on oncology trainee perception of PC. Results: 77/105 (73%) HMO fellows completed the survey (median age of 40 years, 57% males and 82% practicing in an academic setting). The following were reported to improve after the PC rotation: (a) assessment and management of symptoms (98%); (b) opioid prescription (89%), opioid rotation (78%) and identification of opioid side effects (87%); (c) communication with patients and families (91%), advance care planning discussion (88%), DNR discussion (88%); (d) comfort discussing ethical issues (74%); (e) ability to cope with stress of terminal illness (58%). Strongly agree to agree was expressed by 76 (98%) for improved knowledge of symptom assessment & management vs 57 (74%) for ethics (p = 0.0001) and 45 (58%) for coping with stress of terminal illness (p = 0.0001). HMO fellows were more likely to refer patients to PC (83%) for uncontrolled symptoms (97%), psychological distress (88%) or with advanced disease regardless of symptoms (56%) after the rotation. The APCU rotation was felt to be most beneficial (93%). The PC rotation educational experience was felt to be either far better or better (53%) or same (45%) as other oncology rotations. 98% would recommend PC rotations to other HMO fellows and 95% felt rotation should be mandatory. Conclusions: HMO fellows reported PC rotation improved their knowledge in all PC domains, felt PC rotation was far better to better than other oncology rotations, and were more likely to refer patients to PC.

Assessment and knowledge in palliative care in second year family medicine residents.

The implementation and practice of palliative medicine have numerous boundaries in low- and middle-income countries (LMICs), stemming from various cultural, legal, and religious concerns. Additionally, professional education in palliative care medicine in these countries is severely lacking, especially when compared with developed countries. Background/Objectives: To enhance and demystify palliative medicine practice to health care providers in LMICs. Methods: We developed a novel and comprehensive course in palliative care medicine and end-of-life (EOL) care, specifically within the context of management of patients with traumatic brain injury (TBI). We performed both immediate pre-course and post-course analysis of course participant comprehension and feedback, as well as a one-year post-course analysis and small group discussion. Results: The comprehension of the course material was strong, as participants scored an average of 13.9 points better on the post-test compared to the pre-test (49.6% vs. 35.7%, p < 0.001). Participants in the one-year follow-up session reported long-term applicability of the course material in their respective practice settings, with all participants reporting that they utilize the course material often. Small group discussion responses indicated a strong level of comprehension of the course material. Conclusions: Providing education in palliative medicine to health care professionals in LMICs is feasible, and likely to be both well-received and strongly influential to local medical practice. Local cultural and religious practices may be less of a barrier to the provision of palliative medicine than previously considered. Practicing palliative medicine, particularly at EOL, may strengthen patient-provider relationships, improve job satisfaction among health care providers, and improve the perception of medical care provided in LMIC medical settings.

BackgroundMedical assistance in dying (MAID) became legal across Canada when Bill C-14 was passed in 2016. Currently, little is known about the most effective strategies for providing MAID education, and the importance of integrating MAID into existing curricula. In this study, a set of learning objectives (LOs) was developed to inform a foundational MAID curriculum in Canadian Family Medicine (FM) residency training programs.MethodsMixed methods were used to develop LOs based on a published needs assessment from a large, four-site family medicine residency program in southeastern Ontario. Draft LOs were evaluated and revised by faculty and resident leaders using a modified Delphi process and a focus group. LOs were mapped to the existing family medicine residency curriculum, as well as the College of Family Physicians of Canada’s Priority Topics.ResultsNine LOs were developed to provide a foundational education regarding MAID. While all LOs could be mapped to the Domains of Clinical Care within the departmental curriculum, they mapped inconsistently to departmental Entrustable Professional Activities and the Priority Topics. LOs focused on patient education and identification of patient goals were most readily mapped to existing curricular framework, while LOs with MAID-exclusive content revealed gaps in the current curriculum.ConclusionsThe developed LOs provide a guide to ensure family medicine residents obtain generalist-level knowledge to counsel their patients about MAID. These LOs can serve as a model for developing LOs for both family medicine and specialist residency programs in Canada and in countries where MAID is legal.

BackgroundThis study aimed to determine the current state of oncology education in Canadian family medicine postgraduate medical education programs (FM PGME) and examine opinions regarding optimal oncology education in these programs.MethodsA survey was designed to evaluate ideal and current oncology teaching, educational topics, objectives, and competencies in FM PGMEs. The survey was sent to Canadian family medicine (FM) residents and program directors (PDs).ResultsIn total, 150 residents and 17 PDs affiliated with 16 of 17 Canadian medical schools completed the survey. The majority indicated their programs do not have a mandatory clinical rotation in oncology (79% residents, 88% PDs). Low rates of residents (7%) and PDs (13%) reported FM residents being adequately prepared for their role in caring for cancer patients (p = 0.03). Residents and PDs believed the most optimal method of teaching oncology is through clinical exposure (65% residents, 80% PDs). Residents and PDs agreed the most important topics to learn (rated ≥4.7 on 5-point Likert scale) were: performing pap smears, cancer screening/prevention, breaking bad news, and approach to patient with increased cancer risk. According to residents, other important topics such as appropriate cancer patient referrals, managing cancer complications and post-treatment surveillance were only taught at frequencies of 52, 40 and 36%, respectively.ConclusionsCurrent FM PGME oncology education is suboptimal, although the degree differs in the opinion of residents and PDs. This study identified topics and methods of education which could be focussed upon to improve FM oncology education.

In Germany, palliative care has developed rapidly since the establishment of the first palliative care unit in 1983. More improvements in patient-centered care are only possible if legal requirements as well as education of physicians, nurses, and other professionals involved in palliative care are adapted to current needs. This paper provides an overview of legal and regulatory requirements including a critical appreciation of their influence on palliative care in Germany. Only recently has medical education in palliative medicine been implemented as an integral part of medical studies at German universities. Starting in 2014, physicians applying for a license to practice medicine will have to provide a certificate of basic training in this field. The challenge in upcoming years will be the establishment and enhancement of comprehensive, standardized, and quality-controlled education at the universities. Only six universities have established chairs for palliative medicine, and it will be essential to not only establish more chairs but also to involve medical students in the development of the education. Only minimal requirements are specified for education of nurses in palliative care in the legislation. However, standardized and quality-controlled advanced training courses are available. This training is frequently requested as a prerequisite for nurses working in palliative care. Only limited education programs exist for other professional groups that are an important part of the palliative care team. In addition to the development of palliative care for inpatients with an increasing number of palliative care units, hospices, and first chairs of palliative medicine, different forms of ambulant palliative care services have been developed. Changes in the legislation have influenced the situation for home care enormously in the last 5years, also making it more complex. With the Law for the Consolidation of the Competition in Compulsory Health Insurance ("Gesetz zur Stärkung des Wettbewerbs in der gesetzlichen Krankenversicherung"), a legal claim for palliative home care has been implemented in the fifth book of the social law in 2007. The ambitious goal of full coverage with comprehensive palliative home care has still not been achieved in most locations. However, after initial negotiation difficulties between palliative care providers and health insurance funds, an increasing number of contracts have been made. As a consequence-in addition to more than 240 palliative care units in Germany-more than one hundred palliative care teams have begun work in the field of specialized palliative home care. Legal regulations for the supply of opioids and other medications for the treatment of patients at home have been adapted recently, thus, facilitating fast and comprehensive medical treatment in emergency situations. Overall, the legislation has been adapted significantly, hence, contributing to improvements for patients requiring palliative care. It remains to be seen whether additional adjustments are required in the future.

88 Background: In a survey of different cancer centers in the United States, only 23% reported having dedicated palliative care beds and hospital executives have reported not having further plans for expansion of their program. Barriers that are often cited include poor reimbursement for services, limited institutional support and resources. Patients admitted to an Acute Palliative care unit (APCU) benefit from the multidisciplinary approach that is evident in daily rounds, interdisciplinary team meetings, and family conferences. There could be occasionally misconceptions about the differences between inpatient hospice and an APCU. Even though the psychosocial component of palliative care is extremely important a significant amount of medical interventions also are necessary to provide patients and family with a sense of and optimal care during this time. Methods: A retrospective chart reviewed was performed in 100 consecutives patients admitted to the APCU and inpatient hospice prior to October 2013. From this data we identified the acute medical interventions ordered by the palliative Care specialist tduring the first 5 days of admission. Results: A total of 100 patients from the APCU and 100 patients from inpatient hospice were reviewed. In the APCU 100% of patients had iv fluids vs 7% in inpatient hospice. Antibiotics were given in 52% of APCU patients vs 2% in the inpatient hospice. Steroids were given in 48% of APCU patients vs 30% in inpatient hospices. (See Table). Conclusions: The APCU in comparison to inpatient hospices had higher rate of acute medical interventions with the most common been iv fluids, antibiotics, laboratory and radiologic diagnostic tests. This represent the importance of Acute Palliative Care Units in advanced cancer patients with complicated situations to achieve comfort when transitioning to EOL. [Table: see text]

To evaluate the characteristics of patients with advanced cancer who die in an acute palliative care unit (APCU), and the risk factors for death in APCU. Adult consecutive patients with advanced cancer admitted to the APCU in a period of 13months were prospectively assessed. At APCU admission, epidemiologic data, characteristics of admission, cachexia, being on-off anticancer treatment, and Edmonton Symptom Assessment System (ESAS) and MDAS (Memorial Delirium Assessment Scale) were assessed. Patients who died in APCU were extrapolated from the entire sample. A similar random sample of patients who were discharged alive in the same study period, matched for age and gender, was selected for comparison. Fifty-four patients (12%) died in APCU. Statistical differences between died and discharged patients were found in MDAS (p = < 0.0005), admission for cognitive/clinical decline (p = < 0.0005), referral from specialistic home palliative care (p < 0.0005), cachexia (p = 0.018), being off cancer treatment (p = < 0.0005), and symptom burden (total ESAS) (p = 0.002). At the multivariate analysis, independent factors associated with dying in APCU were MDAS (p = 0.006), referral from specialistic home palliative care (p = 0.025), being off cancer treatment (p = 0.002), pain and dyspnea intensity (< 0.05 and p = 0.038, respectively), and total ESAS (p = 0.025). Mortality risk in APCU is associated with home palliative care referral, high symptom burden, and being off-cancer treatment. More proactive and timely end-of-life care is needed for these patients.

Aim: To evaluate the characteristics of patients with advanced cancer who die in an acute palliative care unit (APCU). The second outcome was to evaluate the risk factors for death in APCU. Methods: Consecutive patients with advanced cancer admitted to the APCU in a period of 13 months were prospectively assessed. At APCU admission epidemiologic data, characteristics of admission, cachexia, being on-off anticancer treatment, and Edmonton Symptom Assessment System (ESAS) were assessed. Patients who died in APCU were extrapolated from the entire sample. A similar random sample of patients who were discharged alive in the same study period, matched for age and gender, was selected for comparison. Results: Fifty-four patients (12%) died in APCU. Statistical differences between died and discharged patients atadmission were found in MDAS (p=&lt;0.0005), home palliative care referral (p&lt;0.0005), cachexia (p=0.018), being off-therapy (p=&lt;0.0005), cognitive/clinical decline (p=&lt;0.0005), and symptom burden (P=0.002). At the multivariate analysis, independent factors associated with dying in APCU were MDAS (p=0.006), referral from home care (p=0.025), being off-therapy (p=0.002), pain (&lt;0.05), and dyspnea intensity (p=0.038), and total ESAS (p=0.025). Conclusion: Mortality risk in APCU is associated with home palliative care referral, high symptom burden, cognitive failure, and general worsening of the clinical condition, as well being off-therapy. More proactive and timely end-of-life care is needed for these patients.

INTRODUCTION: To determine the number of obstetrics and gynecology, internal medicine, and family medicine residency training programs with mandatory palliative care rotations. METHODS: We included internal medicine, family medicine, and obstetrics and gynecology programs listed on the Fellowship and Residency Electronic Interactive Database. Program information such as the number of residents per year, geographic location and monthly block schedule for each program were obtained. If the block schedule explicitly mentioned mandatory palliative care rotation for at least two weeks, programs were categorized as: mandatory palliative care program. RESULTS: Overall, 12.4% (146/1,177) programs had mandatory rotation as part of the residency training. Rates of mandatory palliative care rotation were highest amongst the programs in the West-Pacific (29.2%) and lowest for the West-Mountain (3.5%) residency programs. Internal medicine programs had higher mandatory palliative care rotations compared to Family Medicine (17.6% vs 14.3%, P=.048). Obstetrics and Gynecology had the lowest rate at 0.8%. From these programs, 16.2% (2,181/13,434) of the graduating residents each year had mandatory palliative rotation exposure. CONCLUSION: Our findings highlight the lack of focus on primary palliative care training. Despite recommendations from the Institute of Medicine, based on our analysis, majority of graduate medical training programs do not incorporate palliative care in the curriculum. Incorporating palliative care training with other mandatory subspecialty trainings rotations (e.g. cardiology or oncology) would be an important step in this direction to assure the delivery of high-quality end-of-life care.

The aim of this study was, other than assessing clinical outcomes after a comprehensive palliative care treatment in APCU, to report the activity and functioning of APCU in influencing subsequent care trajectory and settings of patients with advanced cancer. A consecutive sample of patients with cancer who were admitted to an acute palliative care unit (APCU) was prospectively assessed. All patients underwent comprehensive palliative care treatment. At admission (T0), patients' demographics, reasons for admission, referral, and recent anticancer treatments were recorded, along with whether they were on/off treatment or uncertain. Subsequent referrals to next care settings and the pathway of oncologic treatment were reconsidered. Symptom intensity was measured by Edmonton Symptom Assessment Scale (ESAS). Five-hundred and twenty patients were surveyed. Clinical deterioration was the most frequent indication for APCU admission. Most admissions were planned (60.8%). At discharge, a significant decrease in the number of "on therapy" patients was reported, and concomitantly, the number of "off-therapy" patients increased (p < 0.0005) in comparison with data recorded at admission. A significant number of patients was assigned to a palliative care setting, including home palliative care or hospice at the time of discharge (p < 0.0005). All ESAS items that significantly improved during admission were significant. Being "off therapy" was independently associated with a lower Karnofsky (p = 0.002), higher global ESAS at discharge (p = 0.032), and discharge to a palliative setting (hospice or home palliative care) (p < 0.0005). Data from the present study has shown that APCU results in a crossroad for patients with advanced cancer, allowing selection for transition of care.

Unexpected Death on an Acute Palliative Care Unit

Acute palliative care units (APCUs) are new programs aimed at integrating palliative and oncology care. Few outcome studies from APCUs are available. We examined the frequency, survival, and predictors associated with home discharge and death in our APCU. All patients discharged from the APCU between September 1, 2003 and August 31, 2008 were included. Demographics, cancer diagnosis, discharge outcomes, and overall survival from discharge were retrieved retrospectively. The 2568 patients admitted to APCU had the following characteristics: median age, 59 years (range, 18-101); male, 51%; median hospital stay, 11 days; median APCU stay, 7 days; and median survival 21 days (95% confidence interval [CI] 19-23 days). Five hundred ninety-two (20%), 89 (3%), and 1259 (43%) patients were discharged to home, health care facilities, and hospice, respectively, with a median survival of 60, 29, and 14 days, respectively (p < 0.001). Nine hundred fifty-eight (33%) patients died during admission (median stay, 11 days). Compared to hospice transfers, home discharge (hazard ratio = 0.35, 95% CI 0.30-0.41, p < 0.001) was associated with longer survival in multivariate analysis, with a 6-month survival of 22%. Multivariate logistic regression revealed that male gender, specific cancer primaries, and admissions from oncology units were associated with death in the APCU, while younger age and direct admissions to the APCU were associated with home discharge. Our APCU serves patients with advanced cancer with diverse clinical characteristics and survival, and discharged home a significant proportion with survival greater than 6 months. RESULTS from this simultaneous care program suggest a pattern of care different from that of traditional hospice and palliative care services.

PurposeAccurate prediction of survival is important to facilitate clinical decision-making and improve quality of care at the end of life. While it is well documented that survival prediction poses a challenge for treating physicians, the need for clinically valuable predictive factors has not been met. This study aims to quantify the prevalence of patient transfer 72 h before death onto the acute palliative care unit in a tertiary care center in Switzerland, and to identify factors predictive of 72-h mortality.MethodsAll patients hospitalized between January and December 2020 on the acute palliative care unit of the Competence Center Palliative Care of the Department of Radiation Oncology at the University Hospital Zurich were assessed. Variables were retrieved from the electronic medical records. Univariable and multivariable logistic regressions were used to identify predictors of mortality.ResultsA total of 398 patients were screened, of which 188 were assessed. Every fifth patient spent less than 72 h on the acute palliative care unit before death. In multivariable logistic regression analysis, predictors for 72-h mortality after transfer were no prior palliative care consult (p = 0.011), no advance care directive (p = 0.044), lower performance status (p = 0.035), lower self-care index (p = 0.003), and lower blood albumin level (p = 0.026).ConclusionLate transfer to the acute palliative care unit is not uncommon, which can cause additional distress to patients and caretakers. Though clinically practical short-term survival predictors remain largely unidentified, early integration of palliative care should be practiced more regularly in patients with life-limiting illness.