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Constructing Hospice & Palliative Medicine Standardized Patient Cases for Internal Medicine, Emergency Medicine, and Family Medicine Residents

Gavin P. Jones1, William F. Bond, M.D., M.S.2, Daniel E. Ray, M.D.3


2.LehighValleyHealth Network/University ofSouthFloridaMorsaniCollegeof Medicine

3.LehighValleyHealth Network

Background: Why Does This Matter?

The cost of has risen at an unsustainable rate over the past decade. End of life care is a particularly expensive component of the American medical system; one out of every four Medicare dollars (greater than $125 billion) is spent on health services for the 5% of beneficiaries who are in their final year of life1. Inefficiencies in EOL care are propagated and sustained, in part, by a tendency of the medical establishment to push for aggressive, life-sustaining treatments in situations where such action is questionable (e.g., implementation of futile therapy). Moreover, the general reluctance of both patients and physicians to engage in a frank discussion about death often hinders the establishment of EOL protocol; whether or not a particular individual wishes to have certain medical interventions (e.g. mechanical ventilation, hemodialysis, or feeding tubes) withdrawn in their final months of life is rarely reviewed in appropriate detail. As such, creating a more rational system of end of life care in theUnited States – one more soundly based around a patient’s personal goals and desired quality of life – is prudent.

The high costs associated with end of life care can potentially be managed and reduced by increasing educational efforts directed at physicians entering fields where EOL care is encountered: Emergency Medicine, Family Medicine, and Internal Medicine. Moreover, studies have shown that both hospice and palliative care have the potential to cut health care costs by decreasing the rate of hospitalization for dying patients2. These services shift the focus (and dollars) away from expensive, curative interventions to techniques of pain and symptom management. Familiarizing EM, FM, and IM residents with the details and nature of hospice and palliative medicine early on in their medical careers (via simulation) may pave the way for more conservative end of life care in the future. It also makes residents more comfortable with the circumstances surrounding patient death and terminal illness, which should help facilitate patient/doctor communication later on. More informed doctors will lead to more informed patients, which will subsequently lead to more informed EOL medical decisions; such is the is the latent philosophy of and impetus for this

1) Wang, Penelope. "Cutting the High Cost of End-of-life Care." CNNMoney. Cable News Network, 12 Dec. 2012. Web. 22 July 2013.

2) Bergman J, Saigal CS, Lorenz KA, et al. Hospice Use and High-Intensity Care in Men Dying of Prostate Cancer. Arch Intern Med. 2011;171(3):204-210. doi:10.1001/archinternmed.2010.394.


What is Hospice?

  • Hospice is not a place, but rather a special concept of care and services directed towards those specifically with life-limiting illnesses
  • Hospice consists of

– Expert medical care

– Pain management and symptom relief therapy

– Emotional, psychological, and spiritual support for the patient and their loved ones

  • Hospice team consists of: physicians, nurses, aides, social workers, spiritual care givers, counselors, therapists and volunteers.
  • Typically, a family member of the patient serves as the primary care giver and helps make decisions for the terminally-ill individual
  • Most hospice care is provided in the patient’s home – though nursing home care and inpatient hospice facilities are growing in popularity

What is Palliative Care?

  • Contemporary palliative care addresses a patient’s quality of life and overall level of comfort
  • Unlike hospice, is not as “holistic” in its approach

– More about physical symptom relief, less about counseling and emotional support

  • Unlike hospice, is complementary to–but not exclusive of–therapies directed at the underlying illness
  • Unlike hospice, is not restricted to individuals with limited health prognoses

– Can actually be administered to help with aggressive disease-targeted treatments (e.g. chemotherapy)

Methods: How to Construct an SP Case

We performed a search within an online curricular repository known as MedEdPORTAL® for examples of Hospice & Palliative Medicine(HPM)-based simulation/standardized patient (SP) actor cases, including each example’s target learner group and content covered. A literature search was conducted for background references in medical education journals, as well as the references of those who had developed HPM simulation curricula in the past. In addition, we consulted local data on deaths inLehighCountyto create cases that would be realistic and likely for residents to encounter at LVHN in the future. The lead author also attended a local HPM workshop for LVHN/ St. Luke’s Hospital fellows and consulted with the fellowship director. Using a template of a standardized patient actor case, four cases were created all of which involve issues in HPM. Each case includes the following components:

1) Case information:

Background information given to learners prior to the case encounter

3-5 learning objectives

Media for learners (CT scan, POLST form, MRI) when relevant

2) SP Actor Information and Script

3) SP Assessment of Learner Form

4) Questions for the Learner Post-Encounter

Case 1: Disclosing Bad News

Name: Arthur Dobson

Background Info:

  • 68-year-old male with an unremarkable medical history
  • Widower and father of two
  • Made a deliberate effort in his life sustain good health by not smoking, exercising, and eating a healthy diet
  • Has a deep-seated fear of hospitals and the medical profession in general
  • Recently admitted to the emergency room complaining of shortness of breath, coughing, pain in his chest, and severe fatigue
  • Chest X-Ray and CT scan revealed significant pleural thickening and fluid accumulation (effusion) around lungs
  • Findings are absolutely indicative of advanced lung cancer; specifically, mesothelioma caused by exposure to asbestos in the past
  • Further cytological tests have been ordered

Case 2: Consent Planning for End of Life Issues

Name: Angela Smith

Background Info:

  • Mrs. Smith has come to the hospice on behalf of her husband Richard, an 85-year-old man suffering from Alzheimer’s disease
  • Richard’s language abilities have waned to the point where he can only communicate using one or two word phrases
  • Is incontinent and immobile
  • Substantial muscle atrophy and a persistent skin infection/sacral decubitus ulcer
  • There is concern that Mr. Smith will soon lose the ability to eat or breathe independently; as such, future plans for a feeding tube and ventilator (life-support measures) need to be reviewed and discussed with his spouse

Case 3: Palliative Care for End Stage Cancer

Name: Melissa Powell

Background Info:

  • 56-year-old woman suffering from metastatic colorectal cancer. Underwent an operation where the tumor-containing portion of her lower bowel was removed and surgically re-sectioned
  • After several month course of chemotherapy, appeared to be in remission
  • Latest CT scan showed persistent liver lesions and new ascites (fluid in the abdomen). Cancer has returned and spread to her liver, reproductive tract, and general peritoneum
  • Abdominal pain has been getting increasingly worse over the past few months, has left her incapacitated and with a poor appetite
  • Stoic and refuses to admit her pain is getting worse.
  • Fears becoming too “out of it” to be present in the affairs of her family, and feels very depressed

Case 4:Withdrawal of Care/Discontinuation of Therapy

Name: Ann Wendell

Background Info:

  • Ann Wendell is a 50-year-old woman who has come to the hospital on behalf of her father, Donald. Donald is 77-year-old man who developed ESRD (End Stage Renal Disease) secondary to diabetic neuropathy
  • He has managed his condition with hemodialysis for seven years
  • Donald is also a bilateral amputee who had previously lived at home with a full time caregiver
  • A recent stroke has left him conscious, but severely incapacitated and verbally unresponsive with little hope of recovery
  • Never completed an Advanced Directive or POLST form. Now that Donald’s physical condition has significantly deteriorated, a discussion with Ann regarding her father’s withdrawal of treatment (and transition to hospice) is urgent

Conclusion: Next Steps

  • Pre/post course knowledge creation and pre-training module (PPT currently under development)
  • Offer this curriculum to EM, FM, and IM residents with slight customization of the curriculum to meet their needs
  • Pre/post course comfort in communication survey (and maybe delayed survey)
  • Post-course evaluation

– Residents overall impression of exercise

  • Assessment of learning

– Testing residents’ direct acquisition of knowledge


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