Journal of Palliative Medicine

In order to estimate the prevalence of palliative care programs in academic hospitals in the United States, we surveyed a random sample of 100 hospitals in the Council of Teaching Hospitals and Health Systems directory. Sixty percent of hospitals provided information. At least 26% of hospitals had either a palliative care consultation service or inpatient unit and 7% had both. Eighteen percent of hospitals had a palliative care consultation service alone, 19% had an inpatient palliative care unit, 22% reported a hospice affiliation, and 17% had a hospice inpatient contract. Additionally, at least 20% of the remaining hospitals were planning a palliative care program. The consultation services had an average daily census of 6; the inpatient units had an average of 12 beds. Palliative care consultation programs were largely affiliated with departments of medicine or hematology/oncology, and were typically staffed by a physician and a nurse. Only half had a dedicated social worker, one third had a chaplain, one third had a pharmacist, and a few included a bereavement coordinator or volunteer director, suggesting that the hospice model of interdisciplinary care is not being adopted regularly in palliative care programs. In comparison, almost half of hospitals noted established pain services. In conclusion, palliative care programs, although found in a minority of surveyed hospitals, are becoming an established feature of academic medical centers in the United States. More detailed information is needed about the type and quality of care they provide.

In the United States, the majority of deaths occur in the hospital but the dying process there is at best unsatisfactory and more likely inadequate for both patients and caregivers. The development of hospital-based palliative care programs (HBPCPs) can vastly improve inpatient end-of-life care. This study is the first to examine the prevalence and characteristics of HBPCPs in the United States, thus providing a snapshot of the characteristics of these HBPCPs. It also serves as a baseline and benchmark against which future development and patterns of HBPCPs can be compared. Phase 1: Data were obtained from the American Hospital Association (AHA) 1998 Annual Survey, on the existence of end-of-life care (EOLC) and pain management (PM) services in U.S. hospitals. Phase 2: A focused survey further assessed programs in Phase 1 and was sent to all registered hospitals that responded affirmatively to the AHA survey questions as having either a PM service, an EOLC service, or both. In phase 1, 1,751 (36%) hospitals reported having a PM service and 719 (15%) had an EOLC service, for a total of 2,015 unique hospitals that had one or both. For Phase 2, 1,120 of 2,015 responded (56%). Of these, 337 (30%) hospitals reported having an HBPCP, and another 228 (20.4%) had plans to establish one. HBPCPs are most commonly structured as inpatient consultation service and hospital-based hospice. They tend to be based in oncology, general medicine, and geriatrics. We also assessed reasons for consultation, patient characteristics, and future development needs. These findings can help guide future funding, educational, and programming efforts in hospital-based palliative care.

In September 2000, the Quality Interagency Coordination (QuIC) Task Force invited the RAND Center to Improve Care of the Dying and Americans for Better Care of the Dying to testify at its National Summit on Medical Errors and Patient Safety Research. In their testimony, the organizations urged the QuIC to consider the special vulnerability and needs of individuals at the end of life in crafting their research agenda. Patients at the end of life are particularly vulnerable to medical errors and other lapses in patient safety for three reasons: (1) substantially increased exposure to medical errors; (2) more serious effects from errors because they cannot protect themselves from risks and have less reserve with which to overcome the effects; and (3) pervasive patterns of care that run counter to well-substantiated evidence-based practices. A national research agenda on preventing medical errors and increasing patient safety must include a focus on how to improve shortcomings affecting these vulnerable patients. The QuIC's preliminary research agenda, released in October 2000, included patients coming to the end of life. The Agency for Healthcare Research and Quality, the lead federal agency for researching patient safety and medical errors, released between November 2000 and April 2001 six Requests for Applications for research into medical errors.

The Institute of Palliative Care in Ottawa, Canada, began its continuing education programs in 1994. Since 1997, the Institute has been developing and delivering a community-based, interdisciplinary palliative care educational program in each of the three regions of its jurisdiction. Members of the local communities work in active partnership with the faculty in the planning, implementation, and delivery of the programs. The comprehensive evaluation strategy includes a component referred to as "serendipitous ripples." These are outcomes that resulted directly from the programs, but were not anticipated. These outcomes reflect impacts on individuals and groups across the three regions and represent some significant impacts in the communities that should improve care of the terminally ill.

Commentators on the history and development of hospice and palliative care can appear inclined toward a revisionist viewpoint that sees something "lost" in recent years from the original concept. The thesis concerning the "secularization of hospice" is one such example. It is suggested that the quality of these debates can be improved by serious scholarly attention to earlier events and circumstances, drawing on contemporary source materials, rather than retrospective viewpoints. This article, based mainly on correspondence from the early 1960s, explores ideas that shaped the early origins of St. Christopher's Hospice, England. It shows how Cicely Saunders and her associates created an Aim and Basis for the hospice that sought to reconcile questions about its religious orientation; its relationship to medicine; and its status as a community. We see how tensions between these were resolved, resulting in a model that would be applicable in other contexts. Without this pragmatic turn, it is unlikely that the hospice movement would have spread so quickly and so far in the 1970s and 1980s.

A working group on teaching palliative care in the home was convened at The National Consensus Conference on Medical Education for Care Near the End of Life. Our consensus statement includes: (1) a justification for education in the home; (2) general guidelines about teaching palliative care at this site; (3) identification of major barriers to training in the home, and some suggestions for overcoming these barriers; and (4) specific suggestions about how and what to teach. We find that the home is an excellent site for training in comprehensive palliative medicine. Housecalls afford an unusually rich and compelling opportunity to learn about the patient's and family's experience of severe illness and the impact of culture and environment on health care, and can have a broad humanizing effect on trainees. We propose that all medical students be familiar with this form of care. Trainees should learn the potential benefits and difficulties of managing terminal illness in the community, appreciate the role of health care teams in assuring safe, secure, high-quality care, and acquire the special knowledge, skills, and attitudes required for providing state-of-the-art palliative care for patients and families facing a terminal illness in the home, including for those dying at home. Instituting education in the home setting will require faculty development, support for more home visiting by physicians, and supervision of trainees in the home by other members of the health care team. Academic medical centers and hospice/home health agencies should collaborate to develop effective training programs.

Caring for the terminally ill and their families is a unique experience. The experiences of our everyday work shape and transform us as individuals and as teams in ways that are sometimes subtle and unrecognizable and other times quite overt and apparent. Yet some of us as palliative care professional caregivers seldom take the time to stop and reflect on the work we do and how it impacts us, both personally and collectively as a team. In this article we share our experiences with a multidisciplinary "Reflection" Group.

Sociodrama is a powerful teaching strategy that combines a case study approach with traditional role-play methodology to illustrate critical issues in end-of-life care. Building on principles of adult learning and communication skills, the sociodrama method enables the skilled facilitator to draw on the learner's past experiences as resources for teaching and reflective practice. This article describes the use of sociodrama in end-of-life education with illustrations from actual sessions including key discussion points, a typical instructional plan and staging tips.

Nausea and vomiting in abdominal cancer is perhaps one of the most difficult symptom complexes to manage, especially when complicated by bowel obstruction. There are many mechanisms of nausea in advanced abdominal cancer with a number of therapeutic interventions that can significantly enhance symptom control and overall quality of life. As with pain, the ideal approach should include a mechanistic analysis of the causes of nausea beginning with a thorough history, followed by a directed physical examination, and selected laboratory studies. The symptom history, in conjunction with a physical examination and directed tests should direct appropriate pharmacologic and nonpharmacologic interventions. The result is often the amelioration of significant suffering and enhanced quality of living.

How do health care consumers, private sector organizations, professionals, and government agencies work toward ensuring quality end-of-life care? This challenge is by no means uniquely Canadian; our approach may thus have applications that extend well beyond our national borders. Raising the profile of palliative care in Canada has occurred on many fronts. Local, provincial, and national efforts in end-of-life care have long been underway. The Canadian Palliative Care Association has been particularly active, recently organizing various stakeholder groups to develop a strong national advocacy partnership for quality end-of-life care. Perhaps most distinctive has been the involvement and nationwide visibility of Canada's Senate. Their report, Quality End-of-Life Care: The Right of Every Canadian has seen Canadian palliative care gain unprecedented momentum. The federal government recently took the unprecedented step of creating a new office to represent palliative care within the federal cabinet. In Canada, it would appear that palliative care is an idea whose time has come.