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Introduction, Schedule, & Assignments

INTRODUCTION:
       In response to recent documentation by SUPPORT (1) and other studies (2,3) that the quality of medical care of patients at the end-of-life is sub optimal in the United States today, the Junior Rotation in Hospice and Palliative Medicine ("Hospice Rotation", 4) was established. The Hospice Rotation is part of a comprehensive educational program in palliative medicine and end-of-life care (5,6) that now a required element in the curriculum of the University of Maryland School of Medicine. The Hospice Rotation builds on content delivered in the Freshman year in the Introduction to Clinical Practice course entitled "Role of the Physician in the Care of Dying Patients--the Interdisciplinary Approach," which is intended to change attitudes of physicians regarding care of the dying, and to provide fundamental concepts of hospice and end-of-life care. The development of the comprehensive educational program in palliative medicine is funded by an R-25 grant from the National Cancer Institute, National Institutes of Health. Dr. Douglas D. Ross of the Program in Oncology, Department of Internal Medicine, is the Principal investigator of the grant.

1. Knaus WA and the SUPPORT Principal Investigators. A controlled trial to improve care for seriously ill hospitalized patients. JAMA 274:1591-8, 1995.

2. Cleeland, CS, Gonin R, Hatfield AK, Edmonson JH, Blum RH, Stewart JA, Pandya KJ. Pain and its treatment in outpatients with metastatic cancer. New England J Med. 330:592-6, 1994.

3. Wolfe, J, et.al., Symptoms and suffering at the end of life in children with cancer. New England J Med, 342:326-33, 2000.

4. Ross DD, Keay T, Timmel D, Alexander C, Dignon C, O'Mara A, O'Brien W. Required training in hospice and palliative care at the University of Maryland School of Medicine. J Cancer Educ 14:132-6, 1999.

5. Grauel RR, Eger R, Finley R, Hawtin C, Keay T, O’Brien W, Pickens N, Schnapper N, Timmel D, O’Mara A, Ross DD. Educational program in palliative care at the University of Maryland School of Medicine. J Cancer Educ 11: 144-147, 1996.

6. Ross DD, O’Mara A, Pickens N, Keay T, Timmel D, Alexander C, Hawtin C, O’Brien III W, Schnapper N. Hospice and palliative care education in medical school: a module on the role of the physician in end-of-life care. J Cancer Educ 12: 152-6, 1997.

COURSE DESCRIPTION:
      The Rotation in Hospice and Palliative Medicine is a module on end-of-life care that is part of the Junior Medical Student's Ambulatory portion of the rotation in Internal Medicine. The rotation is designed for the students to receive two 4 hour classroom and two 4 hour experiential sessions in a home or inpatient hospice environment.

BEHAVIORAL OBJECTIVES:
    At the end of the palliative care rotation, the Junior Medical Student should be able to:

ANALYZE the value of hospice or palliative care as a component of practice in managing specific patient problems;

DEMONSTRATE a compassionate approach to the care of patients with terminal illness; and

DESIGN, in cooperation with the interdisciplinary hospice or palliative care team, a comprehensive plan of care for a patient with a terminal illness.

SCHEDULE FOR EACH MONTH:
    Note: STUDENTS WITH WEDNESDAY CONTINUITY CLINICS WILL MAKE THEIR HOSPICE VISITS (DAYS 2 AND 3) ON the THURSDAY AFTERNOON OF THE SAME WEEK.

SCHEDULE AND DATES FOR 2008-2009 ACADEMIC YEAR: CLICK HERE.

SUMMARY OF ASSIGNMENTS (3):

1. WRITTEN ESSAY - Guidelines

   The greatest obstacle to compassionate care is unconscious defense reactions and the basis of supportive interactions is enough empathy to communicate that you are listening to the terminally ill patient and family about their concerns. This brief hospice rotation is an opportunity for you to consciously examine your own reactions to dying patients and their families.

    Write a short essay (at least 200 words) after your home visits to describe your personal experience. Clearly, we are after the process here, not any particular answer. This will be of value only if you can honestly reflect on the experience.

Describe:

•        Your attitude, mood, or feelings before meeting the patients.

•        Your thoughts and feelings during your initial contacts with patients and the setting in which you found them.

•        Whether this changed in any way over the course of your time with patients.

•        To what degree were you able to empathize with the patients or was it too hard to imagine being in their situation?

•        What was the most challenging characteristic of the patients for you? (e.g., physical debility, appearance, having to think about death, uncertainty about what to do or say?)

•        What did you learn about yourself from this experience that you can use to enhance your relationship with patients in the future?

2. "Take home" exam:

A 60-item objective format exam and answer sheet will be distributed on day 1, for you to complete at home as an "open-book" exercise. You must have the exam completed by 8:00 AM on the morning of the Day 4 Classroom Session! The exam and answer sheet will be collected at the start of the Day 4 classroom session. The exam will be discussed as a learning exercise at the end of the day 4 classroom session.

3. Patient "Work-up":

STUDENT’ NAME:                                           HOSPICE                               DATE:                       

DIRECTIONS: Select one of your home hospice patients, following the information outlined on this worksheet and the guidelines given in class. Do no more than a 3 page write up on the patient. Be prepared to present the patient in the interdisciplinary team (IDT) conference class on the last day of the hospice rotation. Submit your written work up at the IDT to the faculty member. Seek assistance from hospice staff & medical school faculty as needed to complete the assignment.

Patient’s Initials only:

Patient’s Diagnosis                                                                        

Reason for the today’s hospice visit.                                                

Name of hospice staff & title (RN, SW, spiritual care) with you on today’s visit_______________

I.    DATA GATHERING SECTION: 

BIO-PSYCHOSOCIAL: (from chart. staff, patient, family etc) Include pertinent information related to history of illness, past medical history, social history, physical exam signs and symptoms related to problems, hospice history ie. how long has the patient been receiving hospice care, how did the patient learn about hospice and acquire hospice care, how does the patient feel about their hospice experience.

II.   WORKING DIAGNOSES:

III.  PLAN OF CARE:

Include in this section which member of the interdisciplinary team might provide the interventions. Does the patient need any treatments/studies outside of hospice to meet their needs. What do you see as the role of the primary care physician? What was your role as a medical student?

EXAMPLE:  
3^rd Year Medical Student “Case Report” of a Hospice Patient

I.    DATA GATHERING:

HPI:     Mrs. JJ is a 94 year old widow with metastatic squamous cell cancer of the esophagus. The tumor was diagnosed in June of this year, when the patient begun complaining of vague chest discomfort. She underwent numerous tests, including CT and endoscopy, with tissue diagnosis of squamous cell carcinoma, with pulmonary metastases. A tumor board meeting recommended only palliative radiation, should the patient become symptomatic. Because of complaints of increasing shortness of breath, dysphagia with solid food, and some new lower chest pain, the patient was evaluated for hospice services. She had pain (rated 5/10) when swallowing solid foods, but this has been reduced to tolerable levels.

Her current medications for palliation include 0₂ at 2 liters/min, via nasal cannula, and oxycodone/acetaminophen (Percocet 5/325), one tablet q4h and 2 tablets at HS for pain. She also takes docusate, 100 mg po bid, senna, one tablet po bid, and MOM PRN. She occasionally takes Maalox for indigestion or reflux symptoms.

PMH:     Her other medical problems include CAD s/p MI, with 3rd degree heart block treated by a pacemaker, and hypertension for approximately 15 years. Her medications include Dyazide and verapamil SR 240 mg q.d. She also takes lovastatin 40 mg P0 q.d. for hypercholesterolemia, and has been instructed to adhere to a strict low fat diet.

Personal &Social History: She never smoked, never drank. She was married 40 years, and has been a widow for 35 years. She has two children, one of whom lives a half hour away, 6 grandchildren, and numerous great- and great-great grandchildren. The family is very interested and involved in her care. She lives alone in a one bedroom, first floor apartment, where she has lived for the past 22 years. There are four steps up to the front door, and no steps out the back door. The family has offered to help out by having someone stay with her, but she refuses, valuing her independence. She likes to cook her own food. She does not like the low fat diet, but follows doctor’s orders. She has no written advance directives, but has made it clear several times to her care providers and family that she does not want to be kept alive on machines. She has signed a MIEMSS (Maryland Institute of Emergency Medical and Surgical Services) form requesting DNR status. She has told her family and care providers that, “I’m dying.”

ROS: source-patient. Generally feels “OK.” Can hear loud voice in quiet room. Wears trifocals. Dentures. Weight down 7 lbs in last 3 months. Decreased appetite that was not improved by a trial of Megace. Constipation usually relieved by Senokot, uses MOM 30 cc approximately once a week. No hematemesis, melena, or hematochezia. Complains of some episodes of SOB, especially DOE, relieved by rest and 02. Chest pains, pain on swallowing are relieved by the Percocet. Strength OK. No itching, no specific pains now, sleeping well.

PE:   General: alert, thin, elderly African American female sitting comfortably in a chair with nasal 02 on at 2 L/minute.

VS: T 97, P 90, R 24, BP 150/75
Skin:   excellent hygiene, no skin breakdown, good turgor.
HEENT: PERL approximately 2 mm OU, TMs clear, nose clear, mouth edentulous, moist, no lesions.
Neck/back:    no neck nodes, no CVA tenderness, no localization tenderness
Lungs: rales both bases R>L
Heart:  regular rate, variable strength radial pulse, gr ll/VI SEM LLSB PMI at MCL  
Abdomen: soft without hepatosplenomegaly or masses felt, no hernia noted  
Pelvic/rectal: deferred  
Ext:   strength 5/5 in triceps, biceps, brachioradialis, quads, gastroclsoleus, 5/5 in ant tibial. Normal ROM.
Neurological: responds appropriately to all questions, follows all directions. Normal tone. Slightly wide based gait. Decreased vibration and position sense of lower extremity at toes, forefoot. Romberg negative. Reflexes wnl triceps, biceps, quad, Achilles tendons.

II.    WORKING DIAGNOSES:

1. Squamous cell cancer of the esophagus with pulmonary metastases
2. CAD, s/p pacemaker
3. Hypertension, adequately controlled by verapamiil, Dyazide
4. CHF, 20 #2 and #3, controlled by Dyazide
5. Dyspnea 2~ to #1 and #4, controlled with opioid and 02
6. Dysphagia, Chest pain 20 to #1, controlled with opioid
7. Constipation 2~ age, opioid treatment, controlled with senna, MOM
8. Vulnerable living situation
9. Mild sensori-neural deafness
10. Presbyopia
11. NoCPR  

III.  PLAN OF CARE:

1.   Metastatic Squamous Cell Carcinoma of the Esophagus
        •no curative treatment possible
        •emphasis on palliation of symptoms and end of life care
        •discussed with hospice nurse the most likely course of illness, symptom management

2.  CAD; #3. Hypertension; #4. CHF
        •Continue verapamil SR, Dyazide bid, no other specific Rx
        •Discontinue lovastatin, low fat diet.

5.  Dyspnea
        •Continue O₂ by nasal cannula for symptomatic relief
        •Continue Opioid for relief of symptoms

6.  Dysphagia, Chest pain
        •Etiology probably secondary to radiation treatment and primary tumor
        •Continue opioid for pain relief
        •Monitor with 2x per week hospice nurse visits and q 2 week MD visits
        •Recommend soft food to minimize dysphagia, prevent food from sticking.
        •Experiment with different consistencies to find optimal one (paste, puree, liquid)

7.  Constipation
        •Continue senna, docusate, PRN MOM
        •Monitor

8.  Vulnerable living situation
        •Discussed with family, hospice nurse and social worker
        •Plan of care in place for assessing patient and monitoring

9.  Deafness
        •No specific Rx
        •Safety plan takes into account

10. Presbyopia
        • No specific Rx
        • Safety plan takes into account

11. No CPR
        •Patient’s wishes re: life sustaining medical treatments to be honored
        •Witnessed note in chart, family made aware of this
        •MIEMSS form is in the apartment on the bed; bracelet placed on patient
        •Bereavement assessment and plan per hospice team

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