Improving End-of-Life Care in Clinical Teaching Units: The Associated Medical Services, Inc., Fellowship in End-of-Life Care

Chris Frank, MD, CCFP, FCFP; Deb Pichora, RN, MSc; Cori Schroder, MD, CCFP, FCFP; Phil Wattam, MD, FRCPC; Daren Heyland, MD, FRCPC, MSc

Chris Frank, MD, CCFP, FCFP, Deb Pichora, RN, MSc, and Phil Wattam, MD, FRCPC: Department of Medicine, Queen’s University, Kingston, Ontario; Cori Schroder, MD, CCFP, FCFP: Departments of Oncology and Family Medicine, Queen’s University, Kingston, Ontario; Daren Heyland, MD, FRCPC, MSc: Departments of Medicine and of Community Health and Epidemiology, Queen’s University, Kingston, Ontario

Address for correspondence: Daren Heyland, MD, FRCPC, MSc, Angada 4, 76 Stuart Street, Kingston General Hospital, Kingston, ON K7L 2V7; E-mail: dkh2@post.queensu.ca

Conflict of interest: None declared

Can J Gen Intern Med 2006;1:XX–XX

ABSTRACT

Associated Medical Services, Inc., is a charitable organization supporting innovations in academic medicine and health services in Ontario. In 2005, AMS awarded nine fellowships in end-of-life (EOL) care to address the clinical needs of hospitalized non-cancer patients in the terminal stage of their illness. The goals of the fellowship are to improve knowledge, skills, and attitudes of internal medicine residents; to develop interdisciplinary models of exemplary EOL care in internal medicine CTUs; and to improve the overall care of patients with end-stage illness.

SOMMAIRE

Associated Medical Services Inc. est une société de bienfaisance apportant son appui aux innovations en médecine universitaire et services de la santé en Ontario. En 2005, l’AMS a octroyé neuf bourses pour les soins de fin de vie dans le but d’aborder les besoins cliniques des patients hospitalisés qui ne souffrent pas du cancer mais qui se trouvent en phase terminale. Les buts de ces bourses consistent à améliorer les connaissances, les compétences et les attitudes des résidents en médecine interne; à mettre au point des modèles interdisciplinaires de soins exemplaires de fin de vie dans les unités d’enseignement clinique en médecine interne; et à améliorer les soins généraux des patients atteints d’une maladie terminale.

A recent Senate subcommittee report titled “Quality End of Life Care: the Right of Every Canadian”1 advanced the notion that a “quality death” is the right of every citizen and endorsed the principles and practice of palliative care. Traditionally, palliative care has focused on terminal cancer patients enrolled in palliative care programs. Evidence suggests that dying from cancer is not the same as dying from end-stage medical conditions. Non-cancer patients have a less predictable decline, experience more frequent hospital admissions, have do-not-resuscitate orders written later in their hospital course, and are less likely to receive palliative care consultation.2,3 Canadian patients with advanced medical diseases have been shown to be more dissatisfied with their care than are patients with cancer.4

Although the federal government has increased resources for palliative care support at home,5 the majority of Canadians die from non-cancer causes in hospital while under the care of general internists and other medical specialists. Improving end-of-life (EOL) care in this population of patients is an important goal.

Associated Medical Services, Inc., Fellowship in End-of-Life Care

Associated Medical Services, Inc. (AMS), is a charitable organization supporting innovations in academic medicine and health services in Ontario. In 2005, AMS awarded fellowships in EOL care to nine physicians working in six Ontario teaching hospitals to address the unmet clinical needs of hospitalized patients at high risk of dying. The goals of the fellowship are to improve knowledge, skills, and attitudes of internal medicine residents, to develop interdisciplinary models of exemplary EOL care in internal medicine clinical teaching units, and to improve the overall care of patients with end-stage illness. The AMS fellowships will be implemented in the fall of 2006 and will continue over 5 years.

              Studies suggest that physicians’ knowledge and skills related to EOL care is inadequate.6–8 It is not known how much EOL training residents in internal medicine programs in Canada receive, even though residents are the physicians who spend the most time providing direct EOL care in hospitals.9 Residency is a great opportunity to influence EOL care as “residents are in a unique stage of their training; while they have mastered many basic clinical skills they remain open to educational experiences that might alter their lifelong practice patterns.”10

The development of educational initiatives will be a key component of the fellowship. Baseline measurements of residents’ knowledge, attitudes, and self-assessment; staff attitudes; patient and family satisfaction; and organizational culture will be done in the fall of 2006. This information will be used to guide curriculum development. Fellows will attempt to influence the core internal medicine curriculum by introducing EOL content into “traditional” medicine teaching topics (e.g., management of congestive heart failure) and by developing new sessions on EOL care within existing education formats at their centres. These will include academic half-days, sign-over rounds, and mortality/morbidity reviews.

One focus of the fellowship will be to improve resident skills in EOL communication. Internal medicine residents usually play a primary role in communication with sick patients and their families, during regular ward work and in family conferences. It is hoped that fellows will have an impact on residents’ knowledge and skills in communication using a variety of formats such as small group workshops, role playing, and importantly, role modelling. Role modelling has been shown to be an important factor in improving communication skills,11 and increasing fellows’ participation in family conferences and EOL communication will be an important part of improving care. A literature review of studies related to family conferences has been done, and from this review a framework has been developed and distributed to aid in clinical role modelling and formal teaching.

Although, initiatives designed to improve residents’ knowledge of EOL care have been shown to be successful,6,8,12 they may not always lead to a concomitant change in practice or behaviour.13 The fellows will use strategies shown to be helpful in facilitating change in practice, including acting as key physician opinion leaders, small-group problem-solving sessions, practice audit, and feedback. In some sites, EOL objectives have been added to the core internal medicine rotation objectives to promote evaluation of residents in their care of dying patients. Importantly, fellows will try to focus on improving models of care in their sites as a strategy to promote practice change. This includes increasing links with clinical pharmacists, optimizing the process of family conferences, improving links with palliative care services, and developing checklists for complicated discharge planning with dying patients.

Evaluation Strategy

The goal of the evaluation is to assess the impact of the AMS fellowship on resident and staff knowledge, skills, and attitudes; on patient and family satisfaction; and on organizational culture. Residents will be evaluated using a quasi-experimental before-and-after study design. As illustrated in Figure 1, these findings will be used to inform subsequent educational and quality-improvement initiatives.

Figure 1. Overview of the Associated Medical Services, Inc., fellowship evaluation.

Quantity of EOL teaching will be tracked, and changes in resident knowledge and attitudes related to EOL care will be measured using a self-assessment tool based on the Educating Future Physicians in Palliative and End-of-Life Care (EFPPEC) competencies (available at www.efppec.ca), a knowledge test, and the Block and Arnold Attitudes about EOL Care Scale.

The AMS evaluation will be unique in its ability to link measures of residents’ EOL knowledge and attitudes to patient and family feedback on care through the use of the CANHELP questionnaire, a validated Canadian tool to measure satisfaction with EOL care. This will be an important strategy to provide feedback for individual sites.

Summary

Using change strategies known to make a difference in clinical outcomes,14 the multifaceted interventions of the AMS Fellowship in EOL Care has a high probability of improving care for dying patients in clinical teaching units. The evaluation of the fellowship provides assessment of its impact (summative) while assisting in the refinement of the exemplary models of EOL care (formative). It is anticipated that the lessons learned from the fellowship will be applicable to other hospital settings across Canada.

Dr. Frank is a family physician with certification in Care of the Elderly and works in Division of Geriatric Medicine and with palliative care at Queen’s University.

References

1.           Carstairs S, Beaudoin GA. Quality End of Life Care: The Right of Every Canadian. Ottawa: Government of Canada; 2000.

2.           Tranmer JE, Heyland DK, Dudgeon D, et al. The symptom experience of seriously ill cancer and non-cancer hospitalized patients near the end of life. J Pain Symptom Manage 2003;25:420-9.

3.           Tanvetyanon T, Leighton JC. Life-sustaining treatments in patients who died of chronic congestive heart failure compared with metastatic cancer. Crit Care Med 2003;31:60-4.

4.           Heyland DK, Groll D, Rocker G, et al. End of life care in acute care hospitals in Canada. A quality finish? J Palliat Care 2005;21:142-50.

5.              Department of Finance, Canada. Highlights of Budget 2003. Available at: http://www.fin.gc.ca/news03/03-010e.html#Highlights.

6.           Field M, Cassel CK, eds. Approaching Death: Improving Care at the End of Life. Committee on Care at the End of Life, Division of Health Care Services, Institute of Medicine. Washington, DC. National Academy Press; 1997.

7.           Oneschuk D, Fainsinger R, Janson H, Bruera E. Assessment and knowledge in palliative care in second year family medicine residents. J Pain Symptom Manage 1997;14:265-73.

8.           Okon TR, Evans JM, Gomez CF, Blackhall LJ. Palliative educational outcome with implementation of PEACE tool integrated clinical pathway. J Palliat Care 2004;7:279-90.

9.           Tulsky JA, Chesney MA, Lo B. How do medical residents discuss resuscitation with patients? J Gen Int Med 1995;10:436-42.

10.         Fins JJ, Nilson EG. An approach to educating residents about palliative care and clinical ethics. Acad Med 2000;75:662-5.

11.         Whiting N, Frank C. Get the code status: teaching housestaff about end-of-life communication with older patients. Geriatr Today 2004;7(1):6-9.

12.         Liao S, Amin A, Rucker L. An innovative, longitudinal program to teach residents about end-of-life care. Acad Med 2004;79:752-7.

13.         Sulmasy DP, Song KY, Marx ES, Mitchell JM. Strategies to promote the use of advance directives in a residency outpatient practice. J Gen Intern Med 1996;11:657-63.

14.         Grimshaw J, Thomas RE, MacLennan G, et al. Effectiveness and efficiency of guideline dissemination and implementation strategies. Health Technol Assess 2004;8:1-72.