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Palliative care program stresses teamwork
Uses hospitalists trained in palliative care
What makes an award-winning palliative care program? In the case of the program at the University of California at San Francisco, it's the combination of a collaborative approach to individualized patient care; extensive use of hospitalists; and a program that educates practicing physicians and medical, nursing, and pharmacy students and residents.
Those are some of the factors cited by the American Hospital Association when it recently named the UCSF program as one of the three winners of its annual Circle of Life Award for innovative efforts to provide end-of-life care.
"One of the problems in modern hospitals is that all these professionals — doctors, nurses, social workers, pharmacists, physical and occupational therapists, and chaplains — typically work independently," notes Eva Chittenden, MD, assistant professor of medicine at UCSF and acting director of the palliative care service at the UCSF Medical Center. "One of the things we do is break down these barriers. We all discuss the patients and learn from one another, and end up giving patients better care that's comprehensive and individualized."
Collaboration a necessity
Interdisciplinary, collaborative work is essential to such a program, notes Chittenden, asserting that "you can't be a palliative care service without being a collaborative."
Nevertheless, it is the way the collaborative unfolded at UCSF that helped earn it national recognition. On a daily basis, the team meets at 9 a.m. on the wards. It includes a physician, a social worker, often a pharmacist, a chaplain, and often a nurse as well as trainees — fellows, residents, medical students. "We meet in a room and discuss all the patients on the service," says Chittenden. "Then, depending on the needs of the patients that day, we break into smaller groups and work with them — or we may see the patient as a team." Often, however, the size of that team is limited for fear of overwhelming the patient and family.
The team often will touch base in the afternoon as well as to reconvene and discuss what has happened during the course of the day, says Chittenden.
Every other week there is a formal interdisciplinary meeting for two hours. It includes all the physicians on the service; the head of the chaplaincy program and the chaplains; and nurses who are leaders but may not round with the team on a daily basis. Complementary alternative medicine providers are also present, says Chittenden. "We will discuss the patients in a larger framework, and talk about service needs and administrative issues," she explains.
Providing "individualized" care, says Chittenden, "means we are focusing the care on the goals and values of that particular person." In other words, the team does not use a "one-size-fits-all" approach.
"We sit down with the patient, and whoever is important to them, and start by asking that person, 'What's important to you?' 'What are you looking for in the future?' 'What worries you?' 'What do you want to accomplish with the time you have left?'" Chittenden relates. "We discuss their hopes, goals, dreams, worries, anxieties, and fears, and then try to make the medical care we provide fit those feelings, to help achieve those goals." Those goals, she adds, can be medical, social, psychological, or spiritual.
"Let's say, for example, that someone's goal is to get home and spend time with their family — and we're talking about meaningful time," Chittenden offers. "That patient has to have excellent symptom management. If they have severe pain or shortness of breath or significant nausea, they are not going to enjoy their time with their family." Too often, she notes, providers will focus on the disease, and not on issues such as these.
If a spouse or child is in complete denial about the situation, a chaplain or social worker may be brought in for conversations to help everyone understand the patient's status and feelings. "It if is a cancer patient, they can help decide if the patient will have another round of chemotherapy," says Chittenden.
"The patient may consider the burdens greater than the benefits; they may not want to go to the clinic every few weeks to get an infusion that will make them feel sick if the potential benefit is less than 10%."
Using trained hospitalists
The hospitalist group at UCSF is one of the first of its kind in the country, say Chittenden. "We have a large group — at this point, maybe 25 to 30," she says. "We have a core group of six on the service who are certified in palliative care." One of the benefits is that, as hospitalists, they are in the hospital all day long. "This is wonderful, because we need to spend time with the patients and their families," says Chittenden. "We are used to working with an interdisciplinary team."
In addition, she says, it adds to the job satisfaction of the hospitalists. "I like the fact personally that I get to do both types of work [general hospital care and the palliative care]. They are very different," Chittenden shares.
The hospitalists can perform this dual role, she explains, because of their training. "In our [basic hospitalist] training, we often do learn about some of the core skills in palliative care, but we have gone on to get more training, which is critical," Chittenden notes.
Chittenden adds that research by her group shows that having hospitalists in a hospital improves the chances of your palliative program being successful — even if they are not on your service. "They may be an additional source of referrals," she explains.
Education part of hospital's mission
Training the next generation of providers "is a core part of our mission," says Chittenden. "We have education programs in our medical school, nursing school, and pharmacy school — in pre-clinical and clinical areas." In addition, she says, there are programs for medical residents, and for practicing physicians. "We also have a fellowship program — for residents who finished internal medicine and who want to have one or two years in palliative care training."
The clinical elective for fourth-year students has been available since the palliative care program began in 1999, and now 30% of the students elect to take it, Chittenden says. "It's a little early to tell if [graduates of the two-week hospital program] will work with us," she adds.
Of the internal medicine residents, five have gone on to do palliative care fellowships. "This is really new," Chittenden observes.
UCSF also has established the Palliative Care Leadership Center to educate and mentor hospitals around the country interested in starting their own programs. "A group from an interested hospital makes application and comes to our program, which is a very intensive two-day course," Chittenden says. "There is a lot of individual attention and mentoring as they go through a set of modules we created, followed by a year of telephone mentoring."
[For more information, contact: Eva Chittenden, MD, Assistant Professor of Medicine, University of California at San Francisco, Acting Director, Palliative Care Service, University of California at San Francisco, Medical Center, Phone: (415) 514-1758.]