Specialized Palliative & Hospice Inpatient Unit (PHCU): VAPAHCS

The video depicts the story of the late Mr. Jim Cooper who received care at the VA Palo Alto HCS inpatient unit.
OVERVIEW

The VA Palo Alto HCS provides inpatient palliative and hospice care (PCHU) in a 20-bed ward. The average length of stay for patients on this ward is approximately 3 weeks. Our fellows serve as the primary doctors and manage this large ward of medically complex patients. Under the mentoring and supervision of the attending physicians, the fellows serve as “palliative hospitalists”. They are responsible for all aspects of patient care ranging from screening patients for appropriateness for admission, admitting the patients, assessing for bio-psycho-socio-spiritual distress, managing all medical aspects of care, coordinating patient care with various medical subspecialists, working collaboratively within a large interprofessional team ( including nursing, psychology, social work, pharmacy, chaplaincy, occupational therapy, massage therapy, physical therapy, recreational therapy, pet therapy, and volunteers. Fellows serve as the primary care provider for the in-patients and manage all aspects of care. They also work closely with the patient’s family members and provide help and support, including bereavement care.

This specialized PCHU cares for the following Palliative Care patient cohorts:

  • Patients with acute in-patient palliative care needs e.g. patients with intractable pain who need very sophisticated pain management including procedures like epidurals, intrathecals, cordotomy and patients with intractable non-pain symptoms.
  • Patients with serious life limiting illnesses who are actively dying and need in-patient hospice care.
  • Patients with serious life limiting illnesses who need custodial terminal care.
  • Patients with serious life limiting illnesses on home hospice who need respite care.
  • Chronically mentally ill patients who have serious life limiting illnesses and need custodial, palliative and/or hospice care.
ACGME DOMAINS

Patient Care

  • Goals
    Fellows must be able to provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health. Fellows are expected to:
  • Competencies
    1. Perform a history and physical examination (H & P) which includes relevant information from all sources available. The H & P should address the history of the current illness, medical symptomatology, psychosocial and spiritual aspects of care, and patient/family goals of care.
    2. Demonstrate the ability to provide subspecialty-level pain and non-pain symptom management including behavioral problems, at the end of life.
    3. Recognize the signs and symptoms of imminent dying provide care for the patient and family members, and demonstrate coaching skills, as appropriate, to family members regarding the dying process.
    4. Provide guidance and bereavement counseling as a member of the interprofessional inpatient palliative care setting.
  • Objectives
    1. The fellow’s H & P and progress notes will document physical, psychosocial, and spiritual aspects of care, as well as goals of care.
    2. The fellow will complete up to 2 bereavement assessments during the month for selected families with whom the fellow has provided ongoing coached about the dying process.

Medical Knowledge

  • Goals
    Fellows must demonstrate knowledge of established and evolving biomedical, clinical, epidemiological, and social-behavioral sciences, as well as the application of this knowledge to patient care. Fellows are expected to:
  • Competencies
    1. Learn the assessment and management of commonly seen solid tumors and hematological malignancies in a longitudinal in-patient palliative care setting.
    2. Learn the management of common non-cancer diagnoses as well as the symptoms and patterns of advanced disease in a longitudinal in-patient palliative care setting.
    3. Describe prognoses and disease trajectories for common illnesses.
    4. Assess patients for pain and non-pain symptoms and psychosocial symptoms, including the use of validated tools to measure symptom severity.
    5. Master pain management principles, including pharmacological and non-pharmacological therapies.
    6. Explain the physiologic changes of imminent dying.
  • Objectives
    1. The fellow will demonstrate understanding of underlying physiology of patient’s disease processes and symptoms by including appropriate assessments in progress notes.
    2. The fellow will use evidence-based practice in choosing treatment options for patient’s symptoms.

Problem-Based Learning & Improvement (PBLI)

  • Goals
    Fellows must demonstrate the ability to investigate and evaluate their care of patients, to appraise and assimilate scientific evidence, and to continuously improve patient care based on constant self-evaluation and life long learning. Fellows are expected to develop skills and habits to be able to:
  • Competencies
    1. Identify strengths, deficiencies and limits in one’s knowledge and expertise.
    2. Identify and perform appropriate learning activities.
  • Objectives
    The fellow will supervise and teach trainees and medical students who rotate through the ward, under the supervision of the attending that will both directly observe fellows teaching other trainees and solicit feedback from trainees about the quality and quantity of the fellow’s supervision.

Interpersonal & Communication

  • Goals
    Fellows must demonstrate interpersonal and communication skills that result in the effective exchange of information and teaming with patients, their families, and professional associates. Fellows are expected to:
  • Competencies
    1. Communicate effectively with patients and families across a broad range of socioeconomic and cultural backgrounds.
    2. Maintain comprehensive, timely, and legible medical records.
  • Objectives
    1. In discussing the patient’s condition with patients and families, the fellow will use language appropriate to the educational level and culture of others, as evaluated by the supervising physician and other members of the care team.
    2. The fellow will document changes in the patient’s condition or care plan within 24 hours and will alert consultants who are following the patient, either by forwarding the documentation to them or verbally notifying them.

Professionalism

  • Goals
    Fellows must demonstrate a commitment to carrying out professional responsibilities and an adherence to ethical principles. Fellows are expected to demonstrate:
  • Competencies
    1. Compassion, integrity, and respect for others.
    2. Accountability to patients, society, and the profession.
  • Objectives
    1. The fellow will establish a therapeutic alliance with both the patient and the family, particularly while identifying the patient’s goals of care. The supervising attending will directly observe the fellow during at least 2 clinical interactions and also solicit feedback from patients/families regarding the quality of their interactions with the fellow.
    2. The fellow will participate in weekly medication review sessions for medication reconciliation, quality assurance, soliciting feedback from nursing and pharmacy, and will subsequently implement changes based on evidence and the standard of care.

System-Based Practice (SBP)

  • Goals
    Fellows must demonstrate an awareness of and responsiveness to the larger context and system of health care, as well as the ability to call effectively on other resources in the system to provide optimal health care. Fellows are expected to:
  • Competencies
    1. Work collaboratively in interprofessional teams to enhance patient safety and improve the quality of patient care.
    2. Incorporate considerations of cost awareness and risk-benefit analysis in patient care.
  • Objectives
    1. The fellow will make timely referrals to non-physician members of the interprofessional team, including psychology, chaplaincy, and social work for patients with active psychosocial issues and work collaboratively with them to provide effective patient care.
    2. The fellow will choose treatment regimens for symptoms using evidence-based practice and cost-effectiveness.
TEACHING METHODS

The primary vehicle for learning during this rotation will be through the direct provision of care under supervision by the Attending Physician of the VA HPCU Attending Physician in the context of an interdisciplinary team. This experiential learning will be supplemented by:

  1. Formal ongoing weekly fellowship didactic sessions.
  2. Observation of and participation in daily interdisciplinary palliative care clinical meetings, weekly HPCU interdisciplinary care plan meetings and the monthly HPCU Administrative Group meetings (optional).
  3. Ad hoc instruction by the supervising Attending Physician and other inter-disciplinary members of the care team in the context of daily work, which may include but is not limited to mini-didactic sessions, formal and in-formal case-presentations.
  4. Direct observation of clinical care modeled by other clinicians, including the supervising physician and other inter-disciplinary clinicians doing consults.
  5. In addition this rotation will also include fiscal aspects of running a palliative care service in a VA setting including advocating for new program development and expansion of existing programs.
  6. Directed reading, both self-directed and reading as suggested by the Attending Physician. In such reading the emphasis will be on reviewing literature that discusses the evidence base for care options as relate to palliative care patients in a long term care and nursing home setting.
LEVEL OF SUPERVISION
  • Direct observation by the supervising attending for patient care on consultations and inter-professional team meetings.
  • Each patient is presented to the supervising attending who also independently evaluates the patient.
ASSESSMENT METHODS

Initial meeting to determine training goals:

The fellow will have an initial meeting with the HPCU supervising attending physician during which both programmatic competency goals and self-directed learner goals will be discussed.

End-of-rotation de-brief (formative feedback and block rotation evaluation):

The supervising attending will meet with the fellow at the end of the rotation to provide formative and summative feedback, review the evaluation form with the fellow, and discuss to what extent programmatic and self-directed learning goals were obtained. Informally, the supervising physician will solicit feedback regarding the fellow’s performance from the HPCU patients, families, house-staff/trainees and other clinicians, as deemed appropriate. During this feedback session the Attending Physician will solicit fellow feedback regarding the rotation.

Fellow evaluation process and follow-up:

At the end of the PCHU block rotation (duration = one month), Med Hub sends an automated reminder to the PCHU Attending Physician to evaluate the fellow (using a global rating scale) who worked in that particular rotation. The evaluations are captured and collated by the system and aggregate data for individual fellows across various block rotations is available to the program director and will be used for both formative and summative fellow evaluation. When a fellow receives a sub-par evaluation on the rotation an automated trigger will send an alert to the program director who will immediately take necessary remedial action as appropriate.

Specific evaluation methods used in this block rotation are:

Direct observation: Fellow competency in will be evaluated using direct observation during patient care, and the results of direct questioning during clinical care and both bedside ( at the patient’s home setting) and clinical rounds based teaching experiences . Fellows will be observed by faculty during a clinical interaction and their skills will be evaluated by faculty using global rating scales and specific in-patient consult competency assessment checklists (attached).The supervising attending will directly observe the fellow performing at least one major patient care intervention such conducting a family meeting during the month and will observe the fellow’s presentation of recommendations to the PCHU interdisciplinary care team, referring house-staff and other sub-specialty attendings. Global rating scales: Stanford has a Med Hub online evaluation system which is specifically designed to evaluate fellows and faculty using survey questions with ordinal responses.

Rotation specific assessment checklists:

The in-patient consult competency assessment rotation specific checklist is specifically designed to evaluate specific competencies related to this rotation. Attending physician will use this checklist to evaluate fellows at the end of each block rotation. These evaluations will be captured using an online database and collated and used to provide formative and summative feedback to the fellow.