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Background: Practicing physicians require serious illness communication (SIC) skills to ensure high-quality, humanistic care for patients and families as they face life-changing medical decisions. However, a majority of U.S. medical schools do not require formal training in SIC and fail to provide students deliberate practice before graduation. The Massachusetts Medical Schools' Collaborative was created to ensure that students receive foundational SIC training in undergraduate medical education. This Collaborative developed a curriculum-mapping tool to assess SIC at four medical schools. Objective: We aimed to understand existing educational activities across four medical schools and identify opportunities to build longitudinal, developmentally based curricular threads in SIC. Design: From July 2019 to April 2021, faculty, staff, and medical students assessed current educational activities related to five core competencies in SIC, adapted for students from national competencies for palliative medicine fellows, using a curriculum mapping tool. Measurements: The group selected 23 keywords and collected metrics to describe the timing, instruction and assessment for each school's educational activities. Results: On average, there were only 40 hours of required curricula in SIC over four years. Over 80% of relevant SIC hours occurred as elective experiences, mostly during the postclerkship phase, with limited capacity in these elective experiences. Only one school had SIC educational activities during the clerkship phase when students are developing clinical competencies. Assessment methods focused on student participation, and no school-assessed clinical performance in the clerkship or postclerkship phase. Conclusions: Medical schools are failing to consistently train and ensure basic competency in effective, compassionate SIC. Curriculum mapping allows schools to evaluate their current state on a particular topic such as SIC, ensure proper assessment, and evaluate curricular changes over time. Through the deliberate inclusion of SIC competencies in longitudinal curriculum design, we can fill this training gap and create best practices in undergraduate medical education. [ABSTRACT FROM AUTHOR]

Introduction: Despite recent educational advances, the need for a national standardized primary palliative care curriculum for health professions students remains evident. Methods: An interprofessional leadership team developed a set of core learning objectives built on previously published competencies. A survey was then sent to palliative care experts for feedback and consensus. Results: Twenty-eight of 31 objectives met a 75% consensus threshold, 2 were combined with others, and 12 were refined based on survey feedback. Discussion: With interprofessional input at all stages, we finalized a comprehensive list of 26 learning objectives for a primary palliative care curriculum targeting health professions students. These objectives will be widely available through an online course but can also be adopted for use by individual educators across health professions institutions. These objectives and related curriculum are critical to producing practice-ready clinicians who are prepared to care for the burgeoning population of seriously ill patients. [ABSTRACT FROM AUTHOR]

Purpose of Review: Patients with heart failure (HF) have an increased symptom burden and complex psychosocial and decision-making needs that necessitate the integration of palliative care. However, in the current era, palliative care is frequently evoked for these patients only at the end-of-life or in the inpatient setting; rarely is palliative care proactively utilized in outpatients with HF. The purpose of this review is to evaluate the current state of palliative care and heart failure and to provide a roadmap for the integration of palliative care into outpatient HF care. Recent Findings: Recent studies, including PAL-HF, CASA, and SWAP-HF, have demonstrated that structured palliative care interventions may improve quality of life, depression, anxiety, understanding of prognosis, and well-being in HF. Summary: HF is associated with high mortality risk, significant symptom burden, and impaired quality of life. Palliative care can meet many of these needs; however, in the current era, palliative care consultations in HF occur late in the disease course and too often in the inpatient setting. Primary palliative care should be provided to all outpatients with heart failure based on their needs, with referral to secondary palliative care provided based on certain triggers and milestones. [ABSTRACT FROM AUTHOR]

The article offers information on left ventricular assist device (LVAD) technology. Topics include considered that the element of this process is more visceral or immediate than the act of withdrawing LVAD support, particularly for a patient awake and interactive; and examines that the study deepens understanding of current LVAD withdrawal as highly variable and dynamic process with substantial implications for patients' care.

Our patient, as seen through the eyes of a palliative medicine team This 43-year-old woman presents a history that serves as a valuable foundation for discussion of need for a structured platform for delivery of palliative care for persons with pulmonary arterial hypertension and associated right heart failure; as such, her case vignette is succinctly reviewed, with emphasis placed on features relevant to this topic. [ABSTRACT FROM AUTHOR]

Heart failure (HF) affects nearly 5.7 million Americans and is described as a chronic incurable illness carrying a poor prognosis. Patients living with HF experience significant symptoms including dyspnea, pain, anxiety, fatigue, and depression. As the illness advances into later stages, symptoms become more intense and refractory to standard treatments, leading to recurrent acute-care utilization and contributing to poor quality of life. Advanced HF symptoms have been described to be as burdensome, if not more than, those in cancer populations. Yet access to and provision of palliative care (PC) for this population has been described as suboptimal. The Institute of Medicine recently called for better access to PC for seriously ill patients. Despite guidelines recommending the inclusion of PC into the multidisciplinary HF care team, there is little data offering guidance on how to best operationalize PC skills in caring for this population. This paper describes the emerging literature describing models of PC integration for HF patients and aims to identify key attributes of these care models that may help guide future multi-site clinical trials to define best practices for the successful delivery of PC for patients living with advanced HF. [ABSTRACT FROM AUTHOR]

Background: To improve the quality of care for dying patients, experts have called for all clinicians to be able to provide a generalist level of palliative care. Core clinical clerkships provide an opportunity to incorporate palliative care training to address the lack of required palliative care rotations at most U.S. medical schools. Objective: The objective of this study was to identify and quantify missed opportunities to train third-year medical students in generalist palliative care during required core clerkships. Design: This study was a cross-sectional survey of third-year students at a leading U.S. medical school without a required palliative care rotation. Measurements: Students completed a survey during the last 4 months of the 2012-2013 academic year quantifying and evaluating their experiences caring for dying patients. Attitudes were assessed using a scale from a national survey of students, residents, and faculty. Results: Eighty-eight students responded (response rate [RR]=56%). More than one-quarter (26%) never participated in caring for a patient who died. More than one-half (55%) never delivered significant bad news and 38% never worked with a specialist in palliative medicine. Eighty-four percent of students who cared for a patient who died and 60% of students who delivered significant bad news had one or more of those experiences that were not debriefed. Conclusions: At an institution without a required palliative care rotation, third-year medical students rarely or never care for patients who die during core clerkships, and when they do, their teams do not debrief or reflect on these experiences. Clinical faculty, including palliative care consultants, can address missed opportunities for palliative care training during core clerkships by augmenting and routinely debriefing students' experiences giving bad news and caring for dying patients. [ABSTRACT FROM AUTHOR]

Background: Early conversations about patients' goals and values improve care, but clinicians struggle to conduct them. The systems-based Serious Illness Care Program (SICP) helps clinicians have more, better, and earlier conversations. Central to this approach is a clinician conversation guide for patient encounters. While the SICP works for practicing clinicians, it has not been tested with medical trainees.Intervention: We adapted the SICP training to emphasize assessing prognostic awareness and responding to emotion. We developed a 2.5-hour SICP workshop for medical students and medical interns that included large- and small-group work, practice with an actor, and interdisciplinary clinician facilitators. We trained 81 students and 156 interns and obtained anonymous quantitative and qualitative feedback.Outcomes: Eighty-six percent of students and 91% of residents rated the session as "very good" or "excellent" and >90% of all learners would either recommend this training or intended to apply this to their practice. Post-session learner confidence increased in all communication skills. Learners said the training provided a helpful framework and useful language for these conversations. Resident documentation of serious illness conversations in the medical record increased dramatically during the year following training commencement.Conclusions: Grounded in principles of adult learning theory, this training was rated highly by trainees and resulted in demonstrable practice change. These early learners were more flexible and willing to try this approach than practicing clinicians who tend to resist or revert to old habits. A Guide represents a new paradigm for teaching communication skills and is valued by early learners. [ABSTRACT FROM AUTHOR]

Integration of palliative care (PC) into management of patients with advanced heart disease (AHD) improves quality of life and is endorsed by consensus guidelines. Because of the limited availability of specialty PC providers, equipping cardiologists with communication skills for serious illness conversations is paramount to ensuring access to PC for all patients with AHD. Surveys have shown that fellows in training are frequently involved in late goals of care conversations with AHD patients, yet few receive training in communication skills. CardioTalk is a communication skills workshop created using the VitalTalk (www.vitaltalk.org) model, which has been shown to improve communication skills for oncology, nephrology, and geriatrics fellows. Adapting and implementing a serious illness communication skills curriculum for cardiology and heart failure fellows will be feasible, useful, and valued. General cardiology and heart failure fellows participated in a communication skills workshop using a VitalTalk curriculum adapted for AHD. Sessions were taught by VitalTalk-trained educators, and were structured as a short didactic, including skills demonstration, followed by small-group practice with simulated patient actors. We used a structured "talking map" framework for late goals of care conversations, and specifically taught delivering serious news, responding to emotion, eliciting patient preferences and values, and making recommendations. A Likert scale-based questionnaire was used to assess fellows' perceptions of the educational quality of the workshop, as well as the utility of skills learned. Twenty-three fellows participated. Overall educational quality of the workshop was rated highly, with an average score on the Likert scale of 4.8/5 (with 1 - "Poor" and 5 - "Excellent"). Likelihood of using the workshop skills in daily practice was also highly rated, with an average Likert score of 4.8/5 (with 1 - "Not likely at all" and 5 - "Very likely"). Likelihood of recommending this training to a colleague was rated on average 4.8/5 (1 - "Strongly disagree" and 5 - "Strongly Agree"). Qualitative responses suggested fellows took home the importance of responding to emotion rather than cognitive questions, and the utility of using a conversation framework. Fellows requested additional sessions, as well as training in even more complex cases. Equipping cardiology and heart failure fellows with serious illness communication skills using the CardioTalk curriculum is feasible, effective and valued. Fellows were eager to learn, and felt their new skills would translate well into clinical practice. [ABSTRACT FROM AUTHOR]

A letter to the editor is presented in response to the study "Deactivation of a Left Ventricular Assist Device (LVAD) at the End of Life" by E. F. Gafford and colleagues in the 2013 issue.

1. Participants will self-report an enhanced ability to describe preclinical medical and dental students' reactions to early observed encounters with seriously ill and dying patients. 2. Participants will self-report the ability to appraise and apply interprofessional approaches to supporting student wellness in the context of early clinical exposure. Preclinical medical and dental student responses to early observed clinical encounters with seriously ill and dying patients reveal opportunities for faculty to support student wellness. Interprofessional HPM clinician-educators utilize approaches involving validating, educating, and empowering learners following early experiences. Lessons learned from these approaches can inform faculty development around the lived student experience and strategies for proactively supporting student wellness. Previous work highlights the value of preclinical medical student exposure to the practice of hospice and palliative medicine (HPM) and indicates that students may experience strong or unanticipated emotion in early encounters with seriously ill or dying patients. To explore the nature of students' processing of early interactions with seriously ill patients and their families, as well as opportunities for HPM clinician-educators to support student wellness in the context of these experiences. In 2023, 167 first-year medical and dental students at a large urban medical school were assigned a written reflection following a half-day faculty-mentored HPM shadowing experience and debriefing session. An HPM clinician-educator (physician, nurse, social worker, or chaplain) provided a written response to each reflection. Qualitative analysis was utilized to identify themes arising from both student reflections and clinician-educator responses. 150/167 students (90%) submitted reflections; 150/150 reflections (100%) were provided written responses by an HPM clinician-educator. Three primary student content themes were revealed: 1) strong emotions related to witnessing difficult circumstances (e.g., uncontrolled symptoms; imminently dying patients; personally resonant situations), 2) acquisition of new HPM knowledge (e.g., palliative care is not reserved only for end of life), and 3) impact of the experience on anticipated future patient care (e.g., inspiration to build meaningful connections with patients). Primary faculty response themes included: 1) validation of emotion/strategies for self-care, 2) reinforcement of/expanded detail on HPM principles, and 3) sharing personal insights and opportunities for continued professional development. Students' written reflections suggest common themes in processing observations of clinical encounters with seriously ill and dying patients. HPM clinician-educators across professions shared an approach to supporting student wellness that involved validating, educating, and empowering. Lessons learned could inform faculty development around the lived student experience and opportunities to proactively support student wellness. Resilience / Well being / Interdisciplinary Teamwork / Professionalism [ABSTRACT FROM AUTHOR]

Background: Expanding specialty palliative care within complex health systems involves consideration of patients' unmet needs, clinicians' perceptions of palliative care, and the availability of palliative care resources. Prior to this quality improvement (QI) project, palliative care services in our health system primarily served oncology patients.Intervention: We undertook a prospective strategic planning process that included executive sponsorship and engagement of institutional leaders and clinicians to help define which palliative care services were most needed by the health system.Measures: We interviewed and surveyed a broad range of clinicians including physicians, nurse practitioners, and social workers.Outcomes: The two most prominent themes that emerged from the stakeholder engagement process were clinicians' wish for specialty-aligned interprofessional palliative care teams and for expansion of nononcology palliative care access.Conclusion: Careful needs assessment and stakeholder engagement can result in goal-directed and data-driven expansion of palliative care services within tertiary health care systems. [ABSTRACT FROM AUTHOR]

Abstract: Context: Pain is common among patients with advanced cancer despite the dissemination of clinical pain care guidelines. Objectives: We sought to assess the quality of pain care among patients with advanced disease. Methods: We reviewed the records of 85 adult ambulatory patients with advanced breast, lung, and gastrointestinal cancer treated in 2004–2006. Patients’ screening pain intensity scores were at least 7 of 10. Nurse reviewers completed medical record reviews of care rendered at the index visit and over the subsequent 30 days based on the 2004 National Comprehensive Cancer Network pain guideline. An expert panel then rated the quality of the evaluation, treatment, and overall pain care. We used a multivariable model to analyze guideline compliance and resolution of severe pain. Results: Among advanced cancer patients with severe pain, clinicians adjusted pain medications only half the time and made few timely referrals for pain-related consultations. By 30 days after the index visit, 34% of patients continued to report severe pain. The expert panel judged the overall quality of pain care as “fair” or “poor” in about two-thirds of cases because more timely and effective intervention could have reduced the severity and duration of pain. Resolution of severe pain was associated with adjustment of pain medications at the index visit (adjusted odds ratio 3.8, 95% CI 1.3–10.6). Conclusion: There is room for improvement in the pain care of patients with advanced cancer. Additional research is needed to understand the reasons for poor performance. [Copyright &y& Elsevier]