Meeting and Exceeding Hospice and Palliative Medicine Milestones in a Pandemic

Abstract

Dear Editor:

The COVID-19 pandemic erected innumerable barriers to hospice and palliative medicine (HPM) fellowship directors struggling to preserve their fellows' educational experience. As leaders of the Harvard Interprofessional Palliative Care Fellowship, we experienced this difficulty firsthand, including disruptions in group learning, retreats, and clinical rotations.

We grew to recognize, however, that the pandemic also opened opportunities for rich learning that would not have occurred otherwise. As a result, the performance of fellows graduating in June 2020 actually exceeded that of previous years' fellows when assessed using the HPM Reporting Milestones.¹

Our Fellows' Experience in the Pandemic

Fellows served as consultants for COVID-19 patients in the emergency department (ED), medicine wards, and intensive care units (ICUs), and as primary team members in the Massachusetts General Hospital (MGH) COVID-19 palliative care unit. The clinical work included complex symptom management and goals-of-care conversations with families not permitted to see their hospitalized loved ones, in the context of great prognostic uncertainty. Not only did the fellows learn to take the lead in navigating these issues, but they also learned to coach their colleagues in the ED and ICUs how to do them, too. And with faculty support, our fellows grew markedly in their ability to self-reflect and debrief these very complicated cases.

In addition, the pandemic presented unusual opportunities for fellows to learn clinical program development. Both palliative care programs at MGH and Brigham and Women's Hospital completely reconfigured their clinical services in response to the pandemic, and fellows were included in planning meetings and workgroups. They became involved in projects as diverse as helping create the MGH palliative care unit, contributing to a program to help Latinx patients navigate goals-of-care conversations, and coauthoring hospital policies for withdrawal of ventilator support.

Lastly, fellows became involved in a variety of educational initiatives. They helped develop a toolkit of educational resources for clinicians caring for COVID-19 patients with palliative care needs² and mentored medical students to call families of ICU patients and create “Get to Know Me” posters to be hung on patients' doors. And all fellows did formal and informal teaching with residents and fellows caring for COVID-19 patients, providing guidance about opioid management, delirium treatment, and goals-of-care conversations.

Lessons Learned

Although we knew our fellows were deeply engaged in these efforts, we only truly understood the impact on their education when we assessed their performance using the HPM Reporting Milestones, scoring them higher than in any previous year as the result of pandemic-related experiences (Table 1).

Table 1.

Pandemic-Related Activities Promoting Progress in Hospice and Palliative Medicine Milestones

Domain	Relevant milestones	Examples of pandemic-related activities
Comprehensive whole patient assessment	2. Addressing suffering and distress	Caring for patients with dyspnea, delirium, severe anxiety; communicating with distressed families who could not visit loved ones; promoting systems improvements to reduce suffering (e.g., the palliative care compassion packets)
	3. Withholding and/or withdrawing life-sustaining therapies	Caring for dying patients in the COVID-19 ICUs; helping develop protocols for comfort care, withdrawal of ventilator support, etc., and adapting them to this patient population (e.g., special considerations for extubation to reduce risk of clinician exposure to aerosolized viral particles)
	4. Care for the imminently dying	Caring for patients in the MGH COVID-19 palliative care unit; developing protocols to care for imminently dying patients
Medical knowledge	1. Disease trajectories and formulation of prognosis in serious illness	Formulating prognosis using up-to-the-minute data coming from China, Italy, and New York; building consensus within teams about prognosis for individual patients
Medical knowledge	3. Palliative management of nonpain symptoms	Managing complex combinations of dyspnea, delirium, anxiety; helping create educational materials to disseminate evidence-based guidance (e.g., the palliative care toolkit)¹
Systems-based practice	2. System navigation for patient-centered care	Advocating for patients and families, including helping change hospital guidelines to liberalize family visits to dying patients; identifying creative discharge plans in a pandemic; helping develop a program for Latinx patients to define goals of care
Systems-based practice	3. Physician role within health care systems	Leading interprofessional and cross-specialty teams in caring for COVID-19 patients at end of life; advocating for systems changes to improve care (e.g., the ICU iPAD project)
Practice-based learning and improvement	1. Evidence-based and informed practice	Helping create evidence-based educational resources for trainees and colleagues¹
Practice-based learning and improvement	2. Reflective practice and commitment to personal growth	Consistently asking for and responding positively to feedback; helping colleagues on other teams debrief difficult cases
Professionalism	1. Professional behavior and ethical principles	Helping teams navigate ethically complex patient cases in the ICU (e.g., absence of a health care proxy for a suddenly ill young patient)
	2. Accountability and conscientiousness	Helping develop team workflows to meet patient/family/team needs (e.g., corounding in the ICU); leading projects to improve care (e.g., the get to know me project)
	3. Self-awareness and help seeking	Debriefing difficult cases; providing support and tactful feedback to colleagues experiencing strong emotions in dealing with the effects of the pandemic
Interpersonal and communication skills	1. Patient- and family-centered communication	Establishing therapeutic relationships with families despite barriers of distance, technology, and sometimes language; coaching colleagues to do the same through a hotline for difficult conversations
	2. Interprofessional and team communication	Modeling flexible effective communication with patients, families, and colleagues; fostering input from all team members across disciplines (e.g., supporting nurses on the MGH COVID-19 palliative care unit who had not previously cared for patients at end of life)
	3. Communication with health care systems	Navigating institutional politics and advocating with hospital leaders for resources to improve patient care (e.g., work to improve goals of care conversations with Latinx patients, advocacy to change visitor policies)
	4. Complex communication around serious illness	Using shared decision making with patients and families to determine plan of care in cases with high degree of complexity and uncertainty; coaching colleagues to do the same through a hotline for difficult conversations

ICU, intensive care unit; MGH, Massachusetts General Hospital.

The very stressors the pandemic exerted on our fellowship program opened important opportunities for fellows to learn; the trick was to recognize those opportunities as they presented themselves. In retrospect, the most important decision we made was to include fellows in the strategic work of responding to the pandemic rather than trying to protect them from it. The result was to give fellows access to rare opportunities to grow not only in their clinical practice, but in program development and medical education too.

References

Barnett

, Buckholz

, Christensen

, et al.: Development of subspecialty-specific reporting milestones for hospice and palliative medicine fellowship training in the US. J Pain Symptom Manage, 2020; 60:151–157.

Thomas

, Leiter

, Abrahm

, et al.: Development of a palliative care toolkit for the COVID-19 pandemic. J Pain Symptom Manage, 2020; 60:e22–e25.