With just 6,500 physicians board-certified in hospice and palliative care medicine in the U.S., most end-of-life and comfort care discussions fall to general practitioners, not experts in palliative medicine. According to the 2015 Institute of Medicine Report, Dying in America, the best way to fill the gap between the need for palliative care and the scarcity of palliative medicine specialists is to train a broad swath of health care professionals—generalists, specialists, nurses and physician assistants—in having the difficult conversations that come at end of life and when patients are critically ill.
Stanford is making an effort to do just that. The Palliative Care team offers training for providers at all levels, from physicians and advanced practice providers (APPs) to nurses, case managers and others involved in the care of critically ill patients. Its main emphasis is on improving provider-patient communication.
“Studies demonstrate that physicians think these types of conversations are important to understand what matters most for patients who have serious illness,” said Stephanie Harman, MD, medical director of the Palliative Care Service. “But less than half feel comfortable knowing what to say. That’s the gap we want to help address.”
Training for physicians
Providers learn how to approach patients and families to determine what matters most to them, and then align their care accordingly. They are also taught how to deal with the emotional and supportive needs of patients and families.
“Our efforts in education have been focused on training providers in having conversations about what matters most to patients and families,” said Harman. With the support of the Stanford Health Care Communications Program, the team has been offering structured workshops for fellows and APPs in oncology, critical care, geriatrics and palliative care. But Palliative Medicine is also available to teach any group of providers in managing difficult conversations.
“A recent study found that physicians who engage in these conversations are more likely the ones who have had some training,” said Harman.
In November, the 10th annual Stanford University Medical Center Clinical Excellence Summit focused on improving communication near the end of life. Sponsored by the Dean’s Office and the chiefs of staff from Stanford and Packard, the program was a collaborative effort between Ethics and Palliative Care and was attended by 300 clinicians, nurses, administrators and patient and family advocates. The Palliative Medicine department is now preparing to teach physicians and APPs how to have advanced care planning and goals of care discussions with their patients using the VitalTalk curriculum. This educational model grew out of a National Cancer Institute grant to improve communication skills for oncology fellows. So far, five members of the Palliative Care team have been trained to teach VitalTalk, with plans to train more.
“This is an area where training really makes a difference in the quality of the care that our patients and families receive,” said Harman. “It can be very emotionally challenging caring for patients and families who are nearing the end of life.”
Training for nurses
Because nursing plays a crucial role in the improvement of end-of-life care, much of the training being developed is tailored to them. Before opening the inpatient hospice service on B1 earlier this year, Palliative Care trained 50 registered nurses in end of life care. These nurses care for the largest population of comfort care and end of life patients at Stanford, said Karla Schroeder DNP, RN, director Palliative Medicine and Geriatrics for Patient Care Services.
This more extensive training involved four hours of computer module work, followed by four hours of classroom education and four hours of patient simulation, working with trained actors in emotionally charged scenarios. “We really tailored the training to what we thought the B1 nurses needed,” said Schroeder, who developed the program. Simulations used paid actors, coached to react to typical patient and family interactions.
“Nurses ran through the most common scenarios that patients experience from the time of diagnosis to death,” said Schroeder. What does it look like to give bad news? What happens when a family member gets very upset? How do you explain how you’re managing their symptoms? “It’s a very emotional, engaging experience for the provider that they can practice in a safe area,” she said.
But the need for palliative care training is not limited to hospice patients only, said Schroeder. “Everyone needs to know how to manage communication with critically ill patients,” she said. “As providers, we’re trained how to complete tasks. We’re not trained on how to focus on emotional needs, how to respond to concerns or complaints, how to include someone in decisions about treatments.”
To expand the number of nurses who receiving this level of training, Palliative Medicine is offering nursing education classes in February, March, July and September at Stanford and across the Bay Area. The training uses an evidence-based curriculum developed by the End of Life National Education Consortium to improve end of life care, and is taught in a train-the-trainer format. The intent is to have attendees go back to their units and train their colleagues.
“How do we help people understand how to be excellent communicators when difficult conversations have to happen?” said Schroeder. “It’s hard. And people really want to know how to do it well.”
“There is no shame in saying these are hard conversations,” said Harman. “Training is a great stress reliever. It’s important that staff have the education and background to feel equipped.”