Palliative Care Service Rotation
Palliative care provides patient-centered treatment for seriously ill hospitalized and ambulatory patients helping them manage the distress of a serious illness. Palliative care focuses on symptom management, enhancement of function, physical comfort, quality of life, psychosocial support and communication about the goals of medical care. We provide support for the patients as well as their families. Mount Sinai's third year medical students on their Geriatrics rotation are required to spend one week on the palliative care service to learn about pain management, basic communication skills and advance directives. Geriatrics and hematology/oncology fellows are required to rotate on the service as palliative care precepts and skills are integral to clinicians in these disciplines. In addition, fourth year medical students and house staff are invited to participate on our service through elective rotations on the Palliative Care Consultation Service.
There are 2 interdisciplinary teams on service at any one time. Each team includes an attending, fellow, nurse practitioner, social worker, and up to two medical students. The interdisciplinary teams meet daily at 8:00 am Monday through Friday in the Annenberg Building Fifth floor Dean's Conference Room (location subject to change). All new consults are received by the triage nurse or nurse practitioner who assigns the new patients to one of the two palliative care teams. The fellow or resident and the palliative care attending see all new consults on the day of the request. The fellow or resident presents all new patients the following morning at the 8 am meeting. The patients are seen daily to follow-up on treatment recommendations, symptom management, and communication with the patient and their family. Cases which are particularly difficult or of broader interest are presented at the weekly interdisciplinary Clinical Meeting held Tuesdays at 11 am in Annenberg 10-30.
Goals of the Palliative Care Rotation
- To treat common symptoms such as pain, dyspnea, nausea, delirium, depression, constipation, anxiety, and others commonly seen in association with serious illness
- To broaden understanding and appreciation of psychosocial issues such as loss, grief, and bereavement and the impact of illness on patient and caregiver
- To understand issues about self determination, decisional capacity, health care proxies, DNR, surrogate decision making, ventilator withdrawal, withholding or withdrawing
- nutrition and/or hydration, risk/benefit ratio of medical treatments, New York Sate Law and end of life decision making
- To enhance communications skills with patients, families & colleagues, appropriately interacting with patients and their families when communicating "bad news" and leading discussions regarding the goals of medical care, prognosis and plan of care for a range of diagnoses and patient/family preferences
Communication with Colleagues
The attending of record for a given patient must make a referral or agree to the referral. Prior to seeing the patient, the attending should be contacted to confirm that s/he would like us to see their patient, identify important issues to address, and clarify our team's role in communicating with the patient and/or the family around care. It is important to remember that the primary attending may have a long and strong prior relationship with the patient and family. As a consultant, our primary duty is to the attending of record. We also frequently provide 'palliative care' to our colleagues.
All recommendations documented in our consults should be communicated verbally with the patient's primary medical/surgical team. All efforts should be made to involve the primary team in any family meetings that are scheduled.
Mount Sinai does not yet have an Inpatient Palliative Care Unit. The palliative care service can take patients on as primary patients in any available medicine bed in the hospital. Patients on the team may be cared for by either a hospital nurse practitioner or an internal medicine housestaff team. Those patients eligible for transfer or direct admission to the Palliative Care Service include: 1) those with difficult-to-control physical and/or emotional symptoms; 2) those patients (and their families) who need support in coming to terms with a progressive illness and establishing appropriate goals of care; 3) those transferred from critical care units for whom the goals of medical care are focused on comfort. A patient does not have to be "terminally ill" to be appropriate for care by the primary palliative care inpatient team nor does a patient have to have decided to forego life sustaining therapy or have a DNR order. Any requests by other teams to accept patients as palliative care primary patients should be deferred to the attending on service.
The palliative care service uses a consult form that prompts caregivers to note the patient's symptom burden (11 symptoms rated on a 4-point scale), proxy status, DNR status, Karnofsky performance status, and the purpose(s) of the initial consultation (e.g. goals of care, pain, and other symptoms). These data are entered into a database on the day of the initial consultation. Whenever possible, the patient provides the information for the symptom burden assessment. When a patient is not able, the family or team provides a surrogate assessment. The source of the information (e.g. the patient, family, or team) should be documented on the form.
The Hertzberg Palliative Care Institute has weekly meetings which rotate in content between Clinical Staff Meeting, Administrative Staff Meetings and Continuing Education Meetings. These meetings are held on Tuesdays at 10:15 A.M. in Annenberg 10-30. The Palliative Care Clinical Meeting begins immediately thereafter lasting until noon. Selected patients on the service are presented and discussed with input from the interdisciplinary team.
A short, multiple-choice test of important content areas for physicians in palliative medicine is administered at the beginning and at the end of the rotation to give rotators a sense of the areas about which they would like to learn more, and to provide a sense as to whether educational objectives are being accomplished.
Brookdale Department of Geriatrics and Palliative Medicine
One Gustave L. Levy Place
New York, NY 10029-6574