Grant to boost Baylor College of Medicine curriculum in palliative, hospice care

By Dana Benson

Laura J. Morrison, M.D., recalled that when she was in medical school – and even during much of her residency – she had no exposure to palliative care. So the fact that she is now lead physician on a grant that will expand the hospice and palliative medicine curriculum at Baylor College of Medicine is an indication of how far the field has come.

Palliative care is care provided by an interdisciplinary team that focuses on relief of suffering and improving quality of life for persons with serious life-threatening or life-limiting illness and their families. Hospice care for people at the end-of-life is a subset of this.

The palliative care curriculum is being developed through a grant from the End of Life/Palliative Education Resource Program at the Medical College of Wisconsin. BCM was one of only six medical schools chosen of 57 that applied to receive the Medical Student – Palliative Care Education Project grant.

Emerging field becomes official

The new curriculum comes on the heels of Hospice and Palliative Medicine being designated an official subspecialty by the American Board of Medical Specialties in late 2006, noted Morrison, assistant professor of medicine – geriatrics at BCM.

"Palliative care has been an emerging field over the last 20 years in the United States, and it's very exciting that it is now an official subspecialty that residents from multiple specialties can pursue," Morrison said.

Palliative care encompasses many domains, including pain and symptom management, communication about goals of care, spiritual and psychosocial aspects, legal and ethical issues, hospice and community resources and grief and bereavement, Morrison explained. But typically, medical students, residents and doctors focus so heavily on life-prolonging measures that they often overlook palliative medicine.

Addressing gaps in care

"The Hippocratic Oath includes the goal to prevent and relieve suffering, but in our current high-tech driven culture, that isn't given as much attention as the goal to cure and prolong life," Morrison noted. "I hope we can help medical students and physicians realize that those things don't have to be mutually exclusive. They can co-exist."

Palliative medicine has grown out of what Morrison calls "gaps in care," which arise especially at the end of life. The SUPPORT Study and Institute of Medicine have highlighted the undertreatment of symptoms, conflicts around medical decision-making, the burden of caregiving and depletion of financial resources as major deficiencies in the care of patients and families near the end of life.

Morrison cited one study that looked at community-dwelling adults over age 60 with heart disease, lung disease or cancer. More than 80 percent stated they had at least one symptom that they judged as moderate to severe and more than two-thirds had two or more such symptoms. Pain was reported in more than 25 percent of people, she said. Clearly, there is much work to be done – even in the community setting – with pain and symptom management, a goal of palliative care, Morrison said.

"Another interesting chasm is the whole concept of where people would prefer to die," she said. "A Gallup survey from 1996 told us that, when asked on the street, 90 percent of people say they would want to die at home."

But more recent statistics have shown that 70 percent of people are dying in institutions such as hospitals and nursing homes and one in five people now die in intensive care units.

Palliative medicine is often thought of as end-of-life care and while the field has emerged partly because of the aging population, in fact palliative care can be introduced even when a patient is not in a terminal phase, Morrison noted. Palliative medicine should be available to anyone with a potentially life-threatening or life-limiting illness even if cure is a possibility. However, it will take a lot of one-on-one education and support to encourage physicians to see the broader role of palliative medicine, she added.

Building new curriculum

Even though palliative and hospice care is an emerging field, Morrison said in many cases medical students still aren't getting a lot of exposure to it.

The grant-supported palliative care curriculum at BCM will be introduced in the 2007-08 academic year, according to Anne Gill, assistant professor of pediatrics at BCM and principal investigator of the grant. Third-year BCM medical students will visit one of eight local palliative care centers, where they will meet with a patient and the patient's family and conduct a medical history and physical evaluation. Students will be required to write a summary of their patient encounter, focusing on the palliative care domains, and they will also write a reflective essay.

The grant will also support development of enhanced elective opportunities for BCM medical students in palliative and hospice care as well as faculty development initiatives. The faculty development program kicked off in May, when Susan Block, associate professor at the Dana-Farber/Harvard Cancer Institute and a national leader in palliative care, visited BCM. She will serve as a mentor to the BCM grant team throughout the grant period.

One of the requirements of the grant is that the curriculum is self-sustaining, Morrison said, so that it can continue even after the funding ends.

Drawing more doctors to palliative care

Morrison was always drawn to working with elderly patients and those with HIV and cancer. "Working with patients in those areas intrigued me because of the issue of it being terminal and dealing with the question of, how do you work with patients who are eventually going to die?"

Then in 2000, while she was chief resident at MetroHealth Medical Center in Cleveland, Ohio, Morrison participated in a program about incorporating palliative care education into residency programs. "Learning about the spectrum of the curriculum and the focus on communication and all the challenges involved in palliative medicine, that just captured me."

"I hope more doctors go into palliative care," Morrison said. "I'm sure there will be a ceiling because not everyone is cut out for it. But part of the issue is the lack of awareness. Most people don't even know that it's a subspecialty now."