So good morning, everybody. Thank you for joining us so early on a Friday to talk about palliative care and PM&R. My name is Dorothy Tolchin. I'm in the Department of PM&R at Spelding Rehab Hospital and Harvard Medical School. And I have the privilege of working closely with both medical students and residents and teaching principles of palliative care and learning from them and from colleagues at other institutions about sort of where we need to go, where our growth points are, where our priorities should be from the stakeholder side. So we have three presenters this morning. Two of us are up here. And one of us, unfortunately, last minute was sick but rallied and embedded videos presenting her slides within our slides. So we will make an attempt to make this all run. We appreciate your patience in case we run into a tech glitch, but I don't think we will. So I will get started. We have nothing to disclose. So you'll see as we go through our talk, we'll do this in three segments, one each. And at the end of each of our segments, we have camera slides, which are sort of summary slides or high-content slides, which will be opportunities for you to take out your camera and sort of take a picture as sort of references that you can come back to, but won't be slides that we believe are. So our first question, actually, is just to help us get to know you as our audience a little better. There's lots of reasons why people come to this conversation with lots of different backgrounds. And so our question for you is, how comfortable are you incorporating palliative principles into physiatric care right now? So there's three options. And just by show of hands, who would say not at all? And who would say somewhat and very? Excellent. So we have a range of comfort with palliative care, and people come into this conversation with different backgrounds, and I imagine different interests and goals, too. And so I'm excited about that, hopefully, when we sort of get into talking a little bit more together. We'll have a lot to bring to the table. So our objectives for today are, first, to sort of define and go over sort of palliative care and the benefits of applying a palliative approach within PM&R for our patients with serious illness and injury. We hope that you'll have the opportunity to either take away or to review or reinforce a few palliative care tools that PM&R clinicians can learn and integrate into their clinical care, to identify some learning resources to support your ongoing development of your palliative care knowledge and skills, and then also have an opportunity to appraise your current practice for opportunities to provide and teach some principles of palliative care. So for those of you who are already doing it, the opportunity to think about how to amplify what you're doing, and for those who are doing it but maybe not teaching it, to think about where and how you might incorporate some teaching. And so my section, I'm going to sort of introduce us to some key principles here. So first, what is palliative care? So palliative care really is both a philosophy of care and a structured system of care. It can be available for people at any age and at any stage of illness or injury, beginning from the time of diagnosis through bereavement. It can be offered concurrently with active curative treatments. So palliative care is patient and family-centered care that optimizes quality of life by anticipating, preventing, and treating suffering. It addresses physical, intellectual, emotional, social, and spiritual needs over the course of illness and facilitates patient autonomy, access to information, and choice. It can be delivered across the continuum of care. So a palliative layer of care can be delivered wherever we practice, right? In ambulatory clinics, in hospital-based consultation, inpatient palliative care units, post-acute care facilities, in communities, and in homes. And again, palliative care can be provided from the time of diagnosis through bereavement. Now importantly, patients who are eligible for palliative care who may be living with serious illness or injury may or may not have a terminal or imminently terminal disease. This is a little bit different than hospice, which we're not going to belabor, but are happy to talk more about sort of the distinction between palliative care and hospice. So palliative care is applicable to patients who have symptomatic needs of a wide variety, as I described. Whereas hospice is a specific insurance benefit that provides heightened resources and care for patients specifically at the end of life who are anticipated to have a prognosis of six months or less. And it's an important distinction because hospice and palliative care are often conflated to the detriment of our patients who end up not receiving services from which they could benefit. We talk about palliative care, and then the medical subspecialty of physicians who practice palliative care is called Hospice and Palliative Medicine, HPM. So you may see sort of HPM and palliative care sort of used both throughout our talk. So the domains of palliative care. Communication and information sharing is a big part of what we think about and do in palliative care. So what are we communicating about? We're talking about diagnosis. We're talking about anticipating potential progression or other kinds of symptoms that we may be able to foresee, and talking about those that we might not be able to foresee. We're eliciting values, helping patients and families establish goals of care, goals for life, and in some cases, goals for end of life and what that might look like. Supportive decision making, and we as well as conflict resolution in the cases where that arises. We're sharing information with families, with care teams. We're fostering continuity with providers. This all sounds very familiar to many of us who practice in rehab. This is an important area of overlap we'll talk about. In terms of physical symptom management, physical symptoms that are attended to in palliative care range from pain, to nausea, to vomiting, to vomiting, attended to in palliative care range from pain, nausea, emesis, to constipation, fatigue, shortness of breath. Other domains of symptom management that are really important in the palliative care domain are psychosocial and emotional. How do we work with patients through loss of independence, or in some cases, loss of their dignity, of how they feel being in a position of need relative to their family, and having to ask and report and receive help. And then existential, right? What is the meaning of this disease? What does this mean in the context of my faith? Is this fair? Why does this happen to me? Why now? And these are all important domains within palliative care. So palliative care adds value. I think I'm speaking largely to the choir, for those of you who are already here. But at all levels, right? So for patients and for families, there's good evidence showing the value of a palliative care approach in relieving pain, dyspnea, sleep disturbances, constipation, and improving quality of life, and decreasing aggressive intervention at end of life in ways that align with what the patient actually wants. In some cases, even extended longevity. From a clinician perspective, the value of adding a palliative care lens and palliative care approach really helps foster a meaningful therapeutic alliance with patients, right? Attentive to the palliative care needs of our patients and families. Helps us to better understand their goals and values, and then in turn, provide the most meaningful type of care that we can. Palliative care approach also helps us provide ethical medical care. A palliative care approach focuses on advanced planning, and in a timely fashion when patients are best able to participate and engaging with a support system where it needs to be engaged. In terms of hospitals and healthcare systems, palliative care has been shown in a number of ways to save costs, the end of life to improve care, and also to support a clinician, a clinical team on behalf of a patient by adding support for the family and diminishing distress. So how do PMNR and palliative care overlap? I think you're already hearing it as I sort of talk through these things. But there remains a common misconception that palliative care and PMNR are largely exclusive. But they do feature, share many features and goals, and even patient populations. So in terms of our shared approach to care, right, we embrace an interdisciplinary collaborative model of care both in PMNR and in the specialty of hospice and palliative medicine. Both are explicitly patient and family-centered. In both cases, we're focusing on autonomy and quality of life for patients for whom there is often no cure for the primary disabling illness or injury. So we actually come from a very shared space. We share a set of basic symptom management and communication skills. And we see similar patient populations, even though we don't always identify them as such, right? Patients with ongoing psychosocial, emotional, spiritual needs. Patients who are in their current situation have a major impact on their life and their family, and that's important to us, and integrating that into the care we provide. Importantly, the trajectory of a patient's sort of adjustment, if you want to call it that, to their primary diagnosis doesn't necessarily follow the trajectory of that illness or injury. And we in rehab understand that, and palliative care, we understand that too. We also see patients, particularly in neuromuscular medicine, for example, who might have limited life expectancy and have needs for advanced care planning, but may lose their ability to communicate over time. So it's important in both fields that we're thinking about, what can our patients tell us now? What information do we need to gather? And then what conversations can we have over time, and with whom are we going to have them? And so some of our shared patient populations, right? So people with neuromuscular disease, other degenerative neurologic disease, stroke, severe burns, patients with vascular amputation, and even for physiatrists who don't care for patients with sort of more catastrophic life-changing illness or injury, there's still a role for a palliative care lens, even in outpatient musculoskeletal clinics, right? To the extent that that population reflects our aging population overall, there are patients in these clinics who are living with multiple comorbidities and can still benefit from a little bit of a palliative care approach, and some of the communication and symptom management skills that we'll try to talk about today. So who provides palliative care? There's sort of two main ways that palliative care is provided. One is by all clinicians. We call this primary palliative care. This is sort of the basic set of communication and symptom management skills that we apply every day to support our patients. And then HPM, or Hospice and Palliative Medicine Specialists who have fellowship training and can provide a more advanced level of HPM, palliative care. So we sort of think about this. Farris and I were talking about the example, you know, of a patient with back pain, right? So primary care providers see a lot of patients with back pain, but they only refer a subset of them to physiatrists, right? When it's either diagnostically complicated or the management is a little bit complex so we need to be a little bit creative in the management. And that's sort of the way we like to think about, an important way we think about palliative care, right? That we can provide a basic set of skills to care for all our patients, but sometimes when the decision making is complex, the communication is complex, there's a lot of tension between the patient and family or between the patient and the clinical team or among members of the clinical team. And that's when we can really engage our palliative medicine clinicians as specialists. So this is just kind of a picture showing sort of the spectrum of palliative care expertise. Primary, basic palliative care. And this describes as primary, secondary, and tertiary. Secondary being specialist palliative care teams who come in and consult or they see patients in the outpatient setting. Whereas tertiary palliative care is actually palliative care sort of in a dedicated palliative care space, like on a unit for example, where there's such intense need that the patients need to be full-time monitoring care for. So physiatrists do some primary palliative care, right? Excuse me. And we practice these aspects of primary palliative care on a regular basis, even if we're not explicitly calling it that or we're not saying like we're palliative care providers, but we're doing it, right? We're identifying and managing physical symptoms, pain, constipation, agitation. We're assessing and addressing social factors related to care, right? Caregiver capability. What kind of equipment do we need? What are transportation needs? We're eliciting patient and family understanding of illness, excuse me, and disability. We're coordinating effective interdisciplinary care. We're providing effective communication. We're sensitive to considerations particularly around disability and ability to communicate. And some folks who are more trained to do this than others, but we're identifying when we do need to coordinate with specialty palliative care and our hospice services. So we're actually doing a lot of primary palliative care. And not only in our field in PM&R, but across medical and surgical subspecialties. These are the core foundational skills that are being advocated for in training and practice. And so I'm proud to say that we do a lot of this. Recently, the new clinical practice guidelines for quality palliative care were put out. And within those, there are some recommendations that are really relevant to us. They sort of outline what are important primary palliative care skills. And from that, we can sort of distill ways that we as physiatrists can actually expand a little bit on the things that we do every day. So we can develop new skills to enhance our ability to provide our usual comprehensive care. We can learn the tools available for providing basic palliative care needs assessments and sharpen our ability to identify needs. We can identify common sources of physical and non-physical suffering. So we know in PM&R, typically our training does not include a lot of attention to psychosocial needs, to existential suffering and how we address that. But it is part of a patient's medical and health picture and part of their well-being. So that's sort of another leading edge for us in taking care of our patients, addressing reactions to grief and loss. So often, we're sort of trained to be cheerleaders for our patients, which are really important as they get better, but not all of our patients get better and what do we do then? And how do we talk to patients about that? And then, learning more about the role of specialty palliative care and hospice so that we can educate our families is another sort of leading edge for us sort of as a field to kind of beef up our primary palliative care skills. And that's part of deepening our ability to coordinate with palliative care, learning how and when to refer, learning how we can contribute to palliative care teams and have mutual benefit for them and for us. We're pretty good at assessing functional status, making recommendations for appropriate and safe equipment. Those are all skills that are relevant in the palliative setting. So those are things that we can provide in the same way we ask palliative care to help care for our patients. And so let's go with this slide. So this slide is really just to highlight this emerging recognition of the need for a physiatrist to practice palliative care. It's increasingly articulated. This is the statement from the American Heart Association, American Stroke Association about palliative and end-of-life care and stroke. And they say, there'll never be enough palliative care specialists to manage all of the palliative care needs of patients and families with stroke. And the core elements of palliative care should be routine aspects of care for any practitioner caring for patients and families with stroke. And even more specifically, they actually call out physiatrists as some of these providers. So we know we're being called upon. We sort of kind of know it from our daily practice and what we kind of think. But again, increasingly, we're specifically being called upon to elevate our skills for our own patient population. So this is the camera slide. This is sort of a table highlighting sort of the existing physiatric primary care skills that I started talking about a little bit, and then sort of additional primary palliative care skills relevant to physiatry, both for us to work on and for us to think about as a framework when we teach our trainees to be providers of primary palliative care. Hello. So if you're going back to your institutions and you want to make a pitch for more palliative care education, which might include engaging people in our palliative care departments to come teach within PM&R, or adding more clinical resources within your own systems, these are our primary pitches for why we think palliative care is important in this setting. To help physiatry respond to growing patient healthcare needs. We're all in this together, and our population is aging and getting sicker, and other fields are jumping in and training in primary palliative care. To join with other specialties to build a robust primary palliative care workshop. To facilitate physiatry expertise being integrated into the provision of comprehensive palliative care. So when we learn to provide palliative care, we also learn sort of where in palliative care we can add benefit. And this is sort of an untapped area in a lot of places, where we can actually go in and provide rehabilitation and function-based skills that otherwise palliative care teams are not providing. And then, sort of in the same vein, this palliative care physiatry population. So the next part of our talk, we're sort of gonna roll up our sleeves and talk about some key palliative principles. And this is where Andrea Cheville, and she'll video introduce herself. And she wishes she could be here and appreciates everybody being here. We'll see if we can pull her off video down the slides. To talk about, go through some cases that sort of highlight these principles. Centering patient preferences within the prognostically appropriate care plans, building therapeutic alliances with patients in the context of strong emotions, and aligning biomedical and comfort-directed care with a holistic approach. After that, Dr. Brooks is gonna talk about teaching PM&R residents hospice and palliative medicine. So what exactly can we teach them, and how are we gonna teach it? How can we help them to develop palliative care skills? Both so that they can be better clinicians and collaborate with our palliative care colleagues. And also, how can we prepare them to think about maybe engaging in hospice and palliative medicine fellowships, and Forrest will talk more about that as well. So, I am going to turn this over to Andrea. See if this works. Embedded in these slides for these cases, we'll give you a few minutes to sort of pair and share and talk about some of the content she brings up as well. And Dr. Brooks and I will sort of walk around and facilitate those conversations as needed. Hello, my name is Dr. Andrea Chavelle. I'm a clinician researcher, physiatrist and palliative care specialist practicing at the Mayo Clinic in Minnesota. It is a tremendous pleasure to be able to present to you. I deeply regret not being able to be with you in person. Palliative care and rehabilitation medicine are kindred fields in many ways. Perhaps most saliently, neither targets an organ system or specific disease process. Rather, we seek to improve broad domains. In the case of rehab, it's function. While in palliative care, it's comfort and quality of life. Both fields have core defining skill sets that are used as a foundation to realize therapeutic goals. In the case of palliative care, these have been described by Drs. Quill and Abernethy in the New England Journal back in 2013 as primary palliative care skills, which include, they're listed at the top of the slide, communication skills, advanced care planning, patient-centered goal setting, symptom management, and the provision of psycho-emotional support. I would argue that we also have a similar set of primary PMR skills which have not been formally defined but might include impairment-focused diagnostics and treatment, physical modalities and procedures, functional tests, deconstruction with the provision of alternative strategies to maintain autonomy, and therapeutic exercise. And while our focus today is on familiarizing you with primary palliative care skills, I would encourage you to bear in mind how much benefit you can offer your palliative care colleagues by introducing them to primary PMR skills. Among primary palliative care skills, communication is arguably one of the most important and of perhaps most immediate use. Eric Cassell was a, or is, he's now retired, but an internist that spent much of his career writing about the nature of suffering and was a huge advocate of excellent and expert clinical communication. And he provides this quote, which is quite lovely, that all medical care flows through the relationship between physician and patient and that the spoken word is the most important tool in medicine. And I think we would all agree that good communication is of profound benefit to all involved stakeholders. One of the reasons that communication skills enable you to enhance the experience of your patients, but also your colleagues and yourself, is the fact that difficult conversations are inevitable in medicine due to poor prognosis, strong emotions related to pain, loss, prior trauma, the inevitable requirement that we deny some of our patients' requests, as well as the need to touch on charged topics like cost of care. Unfortunately, dissatisfied patients are not only unhappy, but they can also exhaust a practice and they can exhaust you. Good communication skills allow for greater efficiency in conducting this communication, but also ensure humanity during difficult conversations. They enable clinicians to establish effective boundaries and to avoid burnout. They also model and demonstrate the impact of effective communication skills for learners. Now we're gonna shift gears a little bit and talk about some cases that offer an opportunity to consider and practice communication skills. And each case highlights on one of the themes that we've emphasized during this presentation. So the first case offers the opportunity to strategize a means to build therapeutic alliance with patients and families in the context of strong emotion. The patient is an 18-year-old freshman who is day 10 on an inpatient rehab unit following a traumatic spinal cord injury. He's been diagnosed with a C6 Asia A injury. He refuses to engage in wheelchair training and only wants to work on walking on my legs. So you are an inpatient physiatrist who's meeting this patient for the first time. So we are gonna ask you to find a neighbor, pair up and discuss what presents the greatest challenge to this patient's care and how might you approach him to begin to open up healthy discussion about his aversion to participating in conventional therapies and what underlies that. We'll take about three minutes. Drs. Tolchin and Brooks will circulate and be available to support and answer any questions. And then we'll resume the presentation about three minutes. Thank you. Thank you for watching my video. Thanks for watching! Thank you for watching my video. Okay, that's 2 minutes and 45 seconds. We're going to reconvene in about very shortly. All righty, that's three minutes. If we could, again, turn our attention to the front. So as you've probably discovered, there's no shortage of challenges in this case. Those that struck me as most salient- All right, Andrea's back. We can't pause it. We apologize. Are concerned about the patient's understanding of his prognosis. Does he lack clarity or information, or is he in denial? And this highlights a very important need for difficult communication, and that is to do your homework and find out as much information as you can so that you're able to come from a place of at least factual, some factual understanding when you engage with a patient. But far more important than the actual facts in this case are what is the patient's understanding? What does he remember? What conversations have occurred? And right now, we don't know that. Also, we don't really understand yet what emotions he's experiencing. Anger, fear, sadness, all of the above. Fortunately, in palliative communication, we do have a number of very helpful tools, and they all have, as you'll see, useful acronyms. And the one that's most often used for delivering bad news is called SPIKES, and the S stands for Setup, which essentially is a little bit about what we've touched on already, which is becoming as informed as you reasonably can, setting up, recognizing that this may be a challenging discussion. And what we call sometimes is firing a bit of a warning shot letting the patient know, I'd like to take about 20 minutes of your time, however long it takes, is now okay to say this, we're gonna have a discussion. And is there anybody you would like to be with you? And if it's not now, is there a better time? The P in SPIKES is for Assess Perception. Tell me about what you're understanding. What happened during your acute hospital stay? Who's talked to you so far about walking and the likelihood of recovering the ability to walk? The I stands for Invitation and Invite Engagement. It may not be forthcoming, but the simple act of inviting engagement is very meaningful. What questions might you have? Do you wanna know more information about your imaging, what we're finding on your clinical exam? Next, K stands for Knowledge. And this is where actually most of us are comfortable and that's Communicating Biomedical Knowledge. And in this case, we don't wanna use euphemism, jargon, we wanna be as straightforward and candid as possible in language that is accessible to the patient and their family. To help this individual understand that by virtue of the nature of his injury, he is unlikely to ever recover the ability to walk. E is for Emotion, Expect Emotion. These are difficult conversations, unpleasant, unwelcome news for the patient. And it's not our job to make the emotion go away, we can't, that's a setup for failure. But we can be present and we can create space for the patient to transition through the need to experience and express strong emotion. One suggested practice is to name the name or suggest an emotion, I can see that you're worried, I can see that you're upset, please know this is very normal. And reassure the patient you will be there for them. Empathy is something that, it's one of the greatest gifts we can give our patient. And verbal reassurance that we will remain with them, that they have our support and empathy is critically important. And last, the S, Strategize and Summarize. Once the news has been conveyed, some closure has been achieved perhaps to the emotion, then express appreciation for the opportunity to discuss, acknowledge that it's difficult, and summarize, not in excruciating detail, but summarize an overview of what was discussed and next steps. So that's another acronym that is very helpful at times is called NURSE. And this applies to communicating empathy with a patient. The N in NURSE stands for Name the Emotion. You seem anxious, frustrated, overwhelmed. Sometimes you can do it a little indirectly. Occasionally patients in your situation may feel angry, sad. Next is the U, Understand the Emotion. Let me make sure I understand what you're thinking or feeling right now. You don't have to get it right, but the simple ask of inquiring, endeavoring to understand is very powerful. R stands for Respect the Emotion. Letting the patient know you're facing this head on. This is incredibly difficult. You are asking great questions and advocating for yourself. So communicating respect. S, Supporting the Patient. Again, you'll note a little bit of duplication across these acronyms rather. But letting the patient know, I will be with you. I'm here to support you. Whatever feelings come up. Almost impossible to overemphasize the fact that emotion is okay. You're safe to express it with me and I will be here for you. And last, Explore the Emotion. Again, showing interest and a desire to know more about it. All of these can be very impactful and beneficial from a patient's point of view. Now I'm gonna shift gears to a second case which focuses on centering patient preferences within a prognostically appropriate plan of care. The patient is an 84-year-old retired teacher in acute care, status post multiple falls at home. The family adamantly requests an inpatient rehabilitation facility stay but the patient does not qualify. The patient, particularly the son, fears that the patient will end up in a long-term care facility if she does not have the opportunity for rehab at an IRF. So you are the consulting physiatrist meeting the patient's son for the first time and you do not believe that the patient is eligible for IRF level care. So again, we would like you to pair and share and to talk about how would you describe the communication challenge in this case? And what might you do in order to avoid an impasse where you simply get stuck in controversy with the patient and their family? Again, we'll take about three minutes. If you could find a neighbor and Drs. Brooks and Tolchin will circulate and support you. Thank you for watching! Okay, in the interest of time, I cut that a little bit short, but if you could wind up, wind down rather, and we will continue the presentation. This is a tough but all too common scenario when there's strong preferences and attachment to a management plan that may not be feasible, financially sound, or clinically appropriate. I would argue another major challenge in this case is it's unclear that the son, it sounds like, is being a very strong and somewhat aggressive advocate for his mom, but it's not clear whether understanding and preferences are shared among the patient and all family members. So, coming back to that SPIKES acronym, the setup, may be helpful to do a little homework in trying to assess the degree of solidarity and understanding what's been shared before that you initiate the conversation. And for goal setting and revisiting goals of care, we have yet another acronym, REMAP, and the R stands for reframe, and this encourages the need to provide an overview of the situation with attention to the conflict as you see it, or foreshadowing the conflict. In this case, your mom's been falling for some time now and has actually been injured, leading to a hospital stay. I understand that you're concerned about the possibility that she may become dependent. So here we have your mom's getting worse, yes, she's becoming dependent, but this is all occurring in the larger context of progressive decline. Once again, expect emotion, and you may want to, with branching logic, sidetrack into the NURSE acronym briefly. But exploring the emotion that's underlining this very strong and intransigent preference. What worries you about your mom's need to go to a skilled nursing facility? It can be very upsetting when our loved one needs more care than perhaps they can receive at home. Map out values. We're trying to come to a preference and value concordance solution, one that resonates and honors the patient's core value set. So starting to ask questions like, are there activities your mom especially enjoys? Who does she like to spend time with? What gives her meaning? What brings pleasure to her life? And letting folks know that you hear the values and that you are going to endeavor to align care with those values. I'm hearing that you want your mom to be safe, and have pleasure and enjoyment, and ideally to be independent for as long as possible. And you can certainly check in. There's the Ask, Tell, Ask is a common technique that really can apply to any of these conversational or these difficult conversations. But am I understanding that right? Please let me check in with you. Do I understand your mom's values? And last, propose a plan. That's the P. From what you've told me, it sounds like we should work on a plan that lets your mom spend time with family, do the things that she loves, while we find an environment that will enable her to be both safe, but also maximally independent. And with this kind of a discussion, you may not have sealed the deal, but you've gotten substantially closer. The third and last case is used to illustrate aligning biomedical and comfort-directed care within a holistic approach, which is a cornerstone of palliative care. So in this case, it's a 67-year-old retired realtor who has end-stage heart and renal failure, as well as back pain related to lumbar spinal stenosis. The pain recently worsened with new onset radiation to the left lower extremity. The patient seeks relief, but wants to avoid coming to the hospital. The patient's PCP refers him to PM&R for guidance in developing a plan that aligns with his preferences. So once again, and we'll keep this a little shorter in the interest of time, but if you could pair and share and discuss what presents the greatest communication challenge for this patient and what might you address first. And we'll take about two minutes to discuss that. And once again, Drs. Tolchin and Brooks will circulate and offer support and guidance as needed. Dr. Tolchin and Dr. Brooks will circulate and offer support and guidance as needed. Dr. Tolchin and Dr. Brooks will circulate and offer support and guidance as needed. Okay, we've got about 15 seconds left. If you can start to wind down and redirect your attention to the front. And we will continue with the presentation. So as in all the preceding cases, there's no right answer. The challenges that struck me as perhaps most problematic are the fact that he has very significant and advanced multimorbidity, which limit therapeutic options, particularly in light of his desire to avoid coming to the hospital. And certainly any intervention, whether it's procedural or pharmaceutical, is associated with increased risk. We don't know how severe his cardiac and renal disease are, although they're described as in-stage. So in terms of hospice or palliative care eligibility, perhaps a little more understanding is needed. And perhaps most importantly, apart from avoiding the hospital, his goals remain largely unexplored. So in this case, rather than yet another acronym, I'll offer you two back pocket strategies, which truly can be applied very broadly. One is hopes and goals, and the other is statements. So hopes and goals simply refers to eliciting values and desired goals of care. So when you think about the future, what do you hope for? When you think about what lies ahead, what worries you the most? So trying to get a sense of what this gentleman desires, how he sees the future unfolding for him, and what is most concerning for him. It is hard to lose hope when you have goals that are meaningful. And the wish statement is a very potent way of aligning the provider with the patient. It can implicitly acknowledge that the outcome won't happen. This is used, I think perhaps was first introduced in cancer care, when a cure may not be possible. But that doesn't mean that the provider can't desperately hope or wish they could offer that. So I wish we had more effective treatment for your condition. I wish we had some other news to give you. So in conclusion, this is my stab at a photo worthy slide. For context on in this spreadsheet or this table on the right, I've listed different general contexts, delivering bad news, conveying empathy, and revisiting goals. And then have listed the tools and techniques. And if you search for any of these acronyms on the internet, they're readily accessible. So I thank you and we'll turn the podium over to Forrest. Thank you, Dr. Schivel. I think that actually worked out pretty seamlessly. So I'm glad that that worked out. I'm Forrest Brooks. I am a recent PM&R graduate from NYU. I'm actually still there for a Palliative Care Fellowship currently. So now that we've talked a little bit about the basics of palliative care and some tools that we can use, I wanted to talk a little bit more about the nuts and bolts of incorporating palliative care principles into PM&R training. So the way I'm gonna break this down is I'm gonna go through it sort of level by level. I want to talk about how we can incorporate these techniques and practices at every level of physiatric training for residents during fellowship, as well as continuing medical education and for attendings. So what's the rationale for including palliative care training at the residency level? Well, one is that we can develop a lens, a palliative lens, that can be applied to basic routine physiatric clinical encounters that we see during residency. It will also help residents enhance collaboration with specialists and placing consults, and it will also equip residents to apply for fellowship training if they're interested in specialty hospice and palliative medicine advanced training. So I want to start off by going over the current state of palliative care training in PM&R residency programs. So we recently did a national survey of PM&R program directors to sort of try to better understand of what's the current landscape of training in palliative care at the residency level. And what we found is that right now there's not any current national standard for incorporating palliative care or any requirements for incorporating it into residency didactics or clinical rotations. And what we found was there was a wide heterogeneity among different residency programs. So I won't go through all the sort of data here, but I put it on the on the side there. What I wanted to highlight was that there's about 30% of programs nationally that offer no palliative care exposure during residency. So that means no didactics and that also means no elective or required rotations. Among those that do offer palliative care education for their residents, the vast majority are didactics based. That's either didactics only or a combination of didactics and an elective rotation. I do want to point out one other thing is that 97% of programs that we got responses from do report having a palliative care department in their institution, which is something I'll kind of touch on a bit later. So among those that do offer palliative care didactics, we found that the vast majority are offering anywhere from about 30 to 120 minutes of palliative care topics during their didactics. And then we found that the we wanted to know a little bit more about what was actually going into those didactics and it was a pretty wide variety of standard palliative care topics that we've already touched on. Things like advanced communication skills, talking about ethics, advanced symptom management, end-of-life planning. So there's a wide variety of things that are covered among those programs that do offer palliative care didactics. And then the last thing we wanted to figure out was, well, who was teaching these palliative care didactics to residents? What we found was that there was kind of an even split between using both palliative care trained physicians and PM&R physicians or palliative care only physicians without PM&R teachers. There was a small minority that used only PM&R physicians to teach their palliative care topics. So there was a variety in the sort of structure of the teachers that were teaching this content. So I wanted to give a couple of examples, and there's more out there in the literature, but of in other specialties that have incorporated palliative care as part of their residency training. What are some of the outcomes from that? So in family medicine, this program required a four-week rotation in palliative medicine. And what they found afterwards was that it improved comfort with assessing and managing pain, comfort with leading family meetings, and comfort with dealing with ethics at the end of life. And actually all the residents at the end of this four-week rotation agreed that it should be required. In psychiatry, they piloted a kind of 32 to 144 hour sort of flexible hospice and palliative care rotation. And what they found was that it increased self-reported palliative care competence, as well as a sort of test or objective scores for knowledge of pain assessment and management, which is relevant to sort of an area of our training. And then in general surgery, they did a very short two-hour communication skills workshop, which improved self-reported communication preparedness. And they had very positive feedback on this. And actually they did a two-month follow-up later and found that a high proportion of the residents were continuing to self-direct practicing of these skills at that two-month follow-up. So now that we know a little bit about the current state, what have program directors in other specialties thought about the current palliative care offerings in their programs? So in neurology, they did a very similar study and they found that 42% of neurology residency program directors were not satisfied with their program's current palliative care education. And 20% of programs in neurology had no palliative care education. And I like this quote from this systematic review that looked at multiple specialties, because I think it sums it up quite nicely, which is that palliative or program directors across specialties responded that they believe in the importance of palliative care education for their trainees, but report dissatisfaction with their current curricula. And many program directors also expressed a desire to expand their current curricula. So the reason I wanted to touch on these other specialties was just to sort of say that we're not alone in PM&R, that we have some room for improvement. This is kind of a broader topic of discussion in the broader GME space. How about perspectives from residents themselves? So this is just a small survey from a single institution, but we just wanted to understand a little bit more about what residents are thinking about these topics. So if you look at the graph on the left, residents were basically asked about, did they get training in communication skills and breaking bad news? And if so, when was that occurring? So if you look at medical school and or internship, a hundred percent of PM&R residents in that program said that they got some sort of exposure. But during PM&R residency itself, that number drops sort of precipitously. So less than 60% are getting specific training in communication skills, and actually less than 40% are getting specific training and breaking bad news. And then if you look at their self-reported comfort level, residents basically said that they're more comfortable discussing things like a rehab plan, things we do on a day-to-day basis, and less comfortable discussing things like prognosis, which requires some of those advanced communication skills we were talking about. So I wanted to, now that we've sort of talked a little bit about the landscape, I wanted to sort of make a pitch for why incorporating palliative care training into PM&R training can be useful and something we can something we can petition our our programs to incorporate into their training. And one example that I wanted to highlight was using the physical medicine of rehabilitation milestones as an example of how palliative care education can sort of achieve broader PM&R goals. So if we look at the PM&R milestones which were set up by the ACGME and American Board of Physical Medicine and Rehab, there's this list of six sort of domains of milestones. I want to highlight professionalism and interpersonal communication skills. So I took just two of the milestones from the long list that they published, and I took out two quotes from the level 5, which is sort of the highest level that residents can achieve in each domain. So under professionalism, a level 5 resident would basically serve as a resource for others to resolve complex ethical dilemmas, and under interpersonal and communication skills, a level 5 resident would role model shared decision-making in patient and family communication, including those with a high degree of uncertainty and conflict. So you can see that those are areas that sort of fall right in the wheelhouse of palliative care, and we've even talked about a couple of tools that help address that. So that's just an example of how we can use sort of existing frameworks within palliative care to meet PM&R training needs. And it can take a little bit of manpower and time to incorporate these changes into PM&R curriculum and training, so we wanted to suggest some ways that residents can develop these skills right now. So we came up with a five list of things that residents can kind of do on their own if they're interested in developing their palliative care skills, and that would be to build a palliative care approach into their existing physiatric encounters, which we've touched on. If you're seeing somebody with a limited prognosis or that's sort of a complex communication situation, you can use some of these palliative care skills in your day-to-day physiatry training. We recommend engaging program director partnership early on so that they can know of your interest in developing palliative care skills and sort of point you in the right direction. Of course, pursuing an elective hospice and palliative medicine rotation if it's available at your institution, or otherwise doing an out elective. Optimizing shadowing experiences, and so what I mean by that is, for instance, if you have a PM&R trained palliative care doctor at your institution, maybe guiding residents toward that position for some shadowing or research experiences, and then accessing any available resources. I'll go over a slide at the end that has some resources that I think can be really useful. So I mentioned a little bit about time and expertise barriers, so I want to just sort of lay this out as some perceived barriers and potential solutions for incorporating palliative care in residency education. So one of the perceived barriers would be a lack of knowledge of the role for palliative care in PM&R. One solution for that would be incorporating palliative care topics into Grand Browns, into didactics. What about the relatively few palliative trained physiatrists? Well, I think that that's going to be a longer-term thing that we're dealing with moving forward, but education about fellowship opportunities and letting PM&R graduates know that this is something they can pursue as a career opportunity. There's a historic lack of training for the current generation of PM&R attendings, so we can, you know, sort of advocate for continuing medical education, some workshops for attendings. There's, of course, in many locations, there's the geographic separation of the acute rehab hospital from the acute care hospital. Some solutions that have sort of recently, you know, gained traction in the past few years would be things like telemedicine and e-consults to sort of bring in palliative care into the rehab hospital, as well as also thinking about having a designated consultant who could do rounds a couple of days a week. And then in the neurology literature, they've also been thinking about these perceived barriers, and they've cited limited time and lack of expertise, as well. And like I mentioned, sort of integrating palliative care topics into the scheduled didactics, as well as collaborating with the palliative care department, can sort of be solutions to that barrier. So we talked about what residents can do right now. How about faculty? What can faculty do right now to support their residents? So career mentorship, teaching residents about palliative care as a career option, advocating for palliative care opportunities for their residents, and writing strong letters of recommendation for those who want to pursue palliative care fellowship, creating a clinical environment. So you can incorporate primary palliative care skills into your own practice, sort of modeling it for your residents. And also giving residents space and time to reflect on challenging cases that do have these palliative care aspects, and sort of guiding them through a debrief. You can connect and cross-collaborate with your institution's department of palliative care, and then utilize the existing resources that are out there, which again I have on my last slide. Really quickly, I just wanted to switch gears for a second and talk about sort of the nuts and bolts of fellowship training in palliative care. So in general, this is a 12-month training program. It's usually housed within an internal medicine department, but they accept graduates from a whole host of residency specialties. That includes PM&R, also neurology, family medicine, OB-GYN, a whole bunch more. And as of the 2020 to 2021 season, there were 156 accredited programs. And the topics that are taught are things we've already discussed today, things like advanced communication skills, complex symptom management, ethics, caring for patients at the end of life. So that's just an overview of what a resident could expect to learn in a palliative care fellowship. And then I just wanted to highlight this slide. This is actually online. I had a print from PM&R just kind of hot off the press. This is a report of the subspecialty certificates among AB PM&R board of physicians. So if you look, hospice and palliative medicine is the smallest. It's the least subscribed of all the subspecialties at this time. I'm hoping that will change in the future. Right now it makes up about 0.5% of AB PM&R diplomats. And then how about for people in the middle of their careers or attendings who want to increase their palliative care knowledge? Of course there's the option to pursue a traditional fellowship, but that's not always a feasible option. And actually a couple of institutions are already starting to think about a solution to this, which is a mid-career fellowship. So they have these at least Mount Sinai and UPenn. They have some examples of these like part-time, time-variable, competency-based fellowships. So they're kind of flexible. You're basically doing palliative care one to two week rotations on your time off. And once you sort of meet the competencies rather than a 12-month block, then the fellowship is complete. So I think that's a really interesting model to hopefully increase our palliative care workforce. Of course incorporating palliative care grand round speakers and planned workshops. And then self-guided learning with the existing resources that are out there. So the takeaway, just in summary, is that palliative care education is not uniform across PM&R residency programs at this time. Although it may be a useful tool to achieve PM&R specific goals. And palliative care educational opportunities have shown positive benefits for residents in other specialties. And I think it's important to know that hospice and palliative medicine fellowships are an available career path for graduates of PM&R residencies. And the existing resources that are out there can be helpful to supplement self-guided learning and residency education. So I put on this slide a couple of resources that I found particularly useful. I have the American Academy of Hospice and Palliative Medicine, which is sort of our professional organization. They offer some mentorship opportunities. The vital talk courses are really helpful for difficult conversation training. And Ariadne Lab Serious Illness Care also offers structured training and conversations about serious illness. There's a National Hospice and Palliative Care Organization, which is a little bit more patient and family facing. So you can kind of go on there, get some resources for your patients who have questions about this area. And then I really like the Palliative Care Network of Wisconsin's Fast Facts. It's basically a library of a couple of hundred of palliative care topics that walk through. It's almost like an up-to-date for palliative care topics that kind of walks you through hot topics in the field. So with that, I think that concludes our presentation. I want to thank everybody for coming bright and early on a Friday morning. If you have any questions, we'd be happy to take a few. Otherwise, feel free to email us. Thank you. That's one question. But the other question is, in terms of the teaching approaches and different adult learning styles and adult-based learning theories, do you have any simulation-based training in adult-educated? Because my personal bias is, we can do tons of dynamic sessions, but if they don't practice it, if you don't have a deep reading session at the end, where you sit down and talk to your body, how do you feel about this? What were the circumstances? How did it change? What is the next step? It really doesn't get us, get our trainees to the level that we expect. So I was just curious, do you have any experience with that? Yes. Simulation-based training for difficult conversations in the field of palliative care? I can answer from my experience. So for your first question about pediatrics, so there's, I think, from what I've seen out there, there's a couple of different models. So there's some palliative care programs that will just accept pediatrics-trained physicians into their general palliative care program. But then there's also some pediatric palliative care-specific programs. So there's a mix out there. In terms of using simulations for palliative care training, I know my institution does that. We do regular OSCEs and simulations to sort of practice these skills, but also to get direct feedback. Because like you said, I think having hands-on skills, and not only just practicing, but having people observe you and give you feedback, I think is incredibly helpful for some of these really nuanced skills. I don't know about you. Yeah, I echo Forrest's response. I'll share in our own institution, we do serious illness training that's simulation-based. And we've brought it over to our Department of PM&R and have started working on sharpening those cases to be particularly PM&R-relevant and really looking for those overlaps to make them really resonant for our residents when we do that kind of simulation training. So there's definitely models and opportunities available from palliative care. And we are in the early stages as a field, I think, at PM&R and beginning to sort of bring them into our field in the ways that they're relevant. I think a month of pediatric palliative care is required. Yeah. And other programs can have less than a year requirement. Yeah. There's at least one month, that's correct, of pediatric palliative care in HPM Fellowship. And then HPM Fellowships also include practice in different settings. So acute inpatient, doing outpatient, also doing home visits, particularly in the hospice setting. And then the home visit, there's also a range of patient age and situation that you'll see. So there is some pediatrics sort of naturally embedded there as well. Hi. Thank you for the talk. I really appreciate it. That was very helpful. For the mid-career options, I was just having a question. Are those for the attending physicians that are at that whole institution, or are they making this available to attending physicians across the country? And are they doing anything for people outside their home institution? I believe this is for attendings at that institution currently, from my understanding. I don't want to guarantee that answer. I have the websites on there if you want to check for sure. I believe it's for people in that institution at this time. I don't know if other programs are sort of like piloting opening that up. I think one of the limitations would be having to be there for the rotation part. So I think if you're at another institution or remote, I think that would be a little more difficult. But I'm glad to see that they're sort of piloting some novel thinking about fellowship structure. There are also some really robust continuing medical education programs that range from being didactic to also including sort of a mentored project over time. And so Mass General, so my home institution, has programs like that also that you can look online. So there are opportunities for clinicians to come from different places to sharpen their training to the best extent one can do sort of in a remote distance kind of way. It's a good question. Thank you so much. I'm one of the 58 who are board certified in hospice and palliative medicine. I live in Florida, Naples, and we just started a... in the Delta program, so they, also our colleagues and our other specialties have a better understanding of the value we give to the specialty. And we also, this is only our second year, but each year we have had one person who has worked part-time, mid-career, one's a hospitalist. They both live in our community, but have done, sometimes they remain as a hospitalist, but we work out a schedule, so they finish. And then the second person is a nephrologist. That's great. I saw you nodding as you were talking. I had a feeling you were deeply in this too. I just have a question. Thank you for that presentation. almost end-of-life complex medical problems versus when you start a hospice component? That's a good question, do you want to? Yeah, so you're absolutely right that hospice is geared towards patients who are at the last six months of life. I guess maybe one way to think of that is that they, so palliative care is sort of the umbrella and hospice is a small subset of that. So hospice is by definition actually an insurance benefit and you can think of it sort of as intensive palliative care delivered in a variety of settings. So you can get home-based hospice and it includes a certain defined amount of services at home, it's typically like a nursing visit per week, usually maybe up to like, and I'm talking from my New York experience, it could be different in different states, but it's like a weekly nursing visit at home, it's like maybe four hours of a home health aid every day, some PTOT maybe, and then a physician on call. And then they sort of give you your symptomatic medications as well, they deliver that to the home. There's also facility-based hospice where you're basically getting the same services but in like a nursing home setting. So I guess the way to think of it is that hospice is a small branch of palliative care where it's more intensively delivered for patients at the end of life as an insurance benefit. Yeah, I would add to that sort of philosophically is a little bit different. So in the spectrum of palliative care, palliative care can be delivered sort of concurrently with active treatments or attempts at active treatment for the duration that one is sort of receiving palliative care, sort of writ large. When somebody elects a hospice, typically that is part of a bigger picture of decisions that curative treatments will no longer be part of the picture. Often patients and families may have decided that we're not going to aggressively hospitalize or do other kinds of interventions. So it's sort of geared, really sort of focused on sort of aggressive comfort measures typically. Although that can change because of the way that payment systems work. Also when one elects hospice, sometimes it's hard to get durable medical equipment or other kinds of services. So it actually, it is a little bit different and it's important to understand those distinctions once somebody goes on hospice because one can receive palliative care or any other kind of treatment throughout their entire life. They don't have to have hospice if that set of services that would be available maybe isn't relevant to them or their families. Hospice does provide sort of 24-hour access to clinicians, typically a nurse, over the phone so they can guide a family member maybe who's at home with their patient. Hospice often, particularly for patients who are at home, will provide a comfort pack of a range of medications delivered in a number of different ways. Again, so that a family or other care provider can act immediately and do symptom management at home and that's sort of supported. And so for some families and patients, that's the right kind of combination of features. But it's not necessarily right for everybody. So it is an important sort of distinction and choice to make to choose hospice. So looking for the elderly, because I did that as well. And I know there was a fine tune between Judy and me. How would you role map the future of your family to that path? I mean, if I bring a lot of emotion to learn your fractures... So I think it's an excellent question and to your point sort of about context, this sounds like a situation where you can see the bigger context and the family may not necessarily be seeing that context because you know for many reasons including the sort of stress of caring for a patient right it's kind of you go from event to event and then you're scrambling in the middle right so being able to gradually introduce that context as you see the patient like identifying what happened and thinking about so where were we a few months ago and what are we looking all skills that that I imagine you employ regularly and then sort of adding in you know we have these colleagues who provide supportive care it's called palliative care it doesn't mean that we think that your family member is imminently dying although sometimes you know there's the stigma around of it that's not what it is here's what it looks like at our institution and here's how other patients have engaged with it and aligning what you think palliative care might be able to provide with the goals that this patient has so like Andrea was talking about that case right like we hear you talking about how being independent is really important to your family member and then give a concrete example you know our palliative care specialists were able to manage pain without medications in this setting and we have kept patients more independent I wonder if maybe not now or maybe in the future this might be something you know maybe we can invite one of our palliative clinicians to one of our appointments and we can sort of talk about what kinds of things we can provide together and giving that context and and destigmatizing palliative care I think is a big part of us because not just in our field but in sort of the lay land also there's a lot of stigma around what palliative care means or when patients hear palliative care with what they think you mean and how you're judging yeah exactly well thank you everyone so much for coming I really appreciated the discussion and the questions they were great email us if you want any more information and enjoy the rest of the conference thank you

palliative approach

physical medicine and rehabilitation

PM&R

palliative care principles

communication skills

patient-centered care

palliative care education

residency

collaboration with specialists

palliative care training

PM&R programs