A systematic overhaul of the nation’s health care education programs is needed to ensure that future clinicians are prepared to provide palliative and hospice care amid rising demand, according to Dr. Leah McDonald of HopeHealth.
McDonald is a hospice and palliative care physician at HopeHealth. The nonprofit health system offers home health, hospice and palliative care in Rhode Island and southeastern Massachusetts. HopeHealth has a contract with the LifeSpan Health System to provide inpatient hospice and palliative care.
Hospice News recently sat down with McDonald to discuss the keys to expanding palliative and hospice skills as more educational programs take root nationwide. The United States’ health education system is reaching a critical need to expand exposure to interdisciplinary palliative skills amid rising demand, she said.
McDonald graduated in 2020 from HopeHealth’s hospice and palliative medicine fellowship program. The health system operates programs across its three affiliated teaching hospitals, which include The Miriam Hospital, NewPort Hospital and Rhode Island Hospital–Lifespan. The health system also operates palliative fellowships at the University of Rhode Island and The Warren Alpert Medical School of Brown University.
In May 2023 McDonald was added to a pilot program at The Miriam Hospital that combines palliative care and emergency medical services. The program began in October 2022 and has since highlighted a growing need to embed palliative skill-building across the health education continuum, particularly for those going into emergency settings that see complex seriously ill populations, according to McDonald.
HopeHealth HopeHealthWhat led to your interest in hospice and palliative care and stepping into a clinical role?
I have a unique path to hospice and palliative medicine that I think is actually a growing pathway of interest for providers.
I completed an emergency medicine residency program and I really saw a gap in both knowledge and clinical skills in terms of talking to people with life-limiting illnesses about how it affects them. We as physicians can better guide their medical-decision making and help with the strain, the pain symptoms and the overall physical and mental stress that comes with these types of illnesses.
After completing my fellowship at [The Warren Alpert Medical School of Brown University], I took a step back and looked at how I could combine my training in hospice and palliative medicine with my training in emergency medicine. I eventually came to this role that was created last year, where we have an embedded palliative care physician within the emergency department.
What has been your experience in providing hospice and palliative care thus far?
The experience I have in hospice and palliative medicine has been really fulfilling. We see so much love every day in doing this job, because you really get the privilege of being involved in a really difficult part of people’s lives and they are really trusting you and hoping for help and guidance.
The experience I’ve had in particular working in hospice and palliative care in the emergency department is really a privilege. An emergency department visit is a scary and overwhelming experience. It can be the worst day of someone’s life. And so, having the viewpoint of a hospice and palliative physician, we’re seeing the whole picture of the patient. We’re considering every aspect of their care, and we’re really trying to reach their patient-centered goals. It has been fantastic to be able to fill that role.
The Miriam Hospital has piloted a program that combines palliative care and emergency medical services. What was the demand for a program such as this one?
In the big picture, I think that this is going to become the standard of care in emergency medicine and in hospice and palliative medicine as we’re seeing an aging population with more high-care needs.
The program started at The Miriam Hospital, a large community hospital that sees a lot of complexly ill older populations. The hospital saw an opportunity to bring goals of care discussions and quality palliative care earlier into patients’ clinical courses. It’s [about] having a hospital institute that really embraces palliative care and allows it to grow and flourish for good quality outcomes.
What were some keys to launching palliative education initiatives in emergency settings?
A couple things that have made this program successful for us.
A key is having someone dual trained in emergency medicine and palliative care who can facilitate these discussions immediately when a patient arrives at the hospital to make sure we’re delivering goal-concordant care at every level. That means we are doing palliative interventions with people’s goals in mind, which might mean avoiding a hospital admission.
The ability to have staff who are dual-trained clinicians is difficult, there’s not many of us. It’s having a diverse group of providers so people are flexible and feel comfortable working in the emergency department.
It’s making sense of what a person wants and is hoping for in terms of their long-term trajectory. It’s [also about] assessing whether they’re in a situation with a very limited prognosis to be able to appropriately communicate their options and allow the patient to make the decisions that are right for them.
We are also very lucky that we partner with a strong hospice institution with HopeHealth. Having a strong hospice affiliation within an academic setting of a community hospital really allows for easy, trusted transitions of care for people who may elect the hospice benefit.
How has the palliative emergency program developed since its inception? What are some of the overall goals and outcomes?
We’ve seen great success within a short period of time. We had a goal of gauging how many palliative patient consults were initiated within the first six months to see what were the needs of someone in the emergency department and their goals of care. Were we discussing appropriate goals of care? Where were we potentially saving a hospital admission when it made sense with the patient’s goals? Was this resulting in a reduced hospital burden and length of stay, as well as financial burdens to the health care system?
We very easily met these goals within the first six months. We have now expanded and piloted the same program at Rhode Island Hospital in January, hiring hospice and palliative clinical teams trained in ER medicine. This is a big step, since the hospital has a large tertiary care center and is a level-one trauma center seeing a lot of cardiac and neurosurgical cases. It’s also affiliated with the Cancer Institute. So that diverse patient population now has these palliative services built into emergency care.
It’s the biggest difference for patients with more medically complex, chronic diseases that tend to have more invasive care as part of their treatment plan for a long time. These programs really allow us to better coordinate care between outpatient providers and the health care system at the intersection of the emergency department. It’s being stationed in that emergency setting to best coordinate making sure their symptoms are well-controlled, they feel supported and they are comfortable with care transitions across the continuum.
More hospice and palliative medicine fellowship programs have cropped up in recent years. What are the main considerations for sustainability and growth for fellowships?
In the last few years since I’ve graduated we’ve definitely seen more new programs popping up across the Northeast and in Massachusetts. A couple reasons why that’s happening is to help sustain growth in this field.
Providers across all specialties are realizing the importance of learning how to appropriately discuss goals of care. There’s growing interest in either incorporating palliative care into primary care practice or developing more hospice and palliative care clinicians within health systems. It’s about training more people to help do this great work in an evidence-driven field.
We need to support creating educational benchmarks that have hospice and palliative care medicine more systematically implemented across the country. Training in pain and symptom management [and] goals of care discussions … These are landmarks to allow more people to have greater consistent care nationwide.
What are some of the biggest challenges in end-of-life and serious illness care delivery? What are ways to address those challenges?
Resources are limited among an aging population with high care needs. The biggest need is how we appropriately transition people’s care outside of hospital setting into people’s homes, clinics or facilities, and to end-of-life care when it makes sense
Also, patients could benefit from hospital-at-home [and] better hospice care in long term care facilities, investing in how we can better support palliative needs in those settings.
Our resources are limited. The United States is seeing this growing aging population that has high-care needs. The biggest need is how we appropriately transition people’s care outside of the hospital setting. It’s bringing palliative medicine consults outside of the hospital and into people’s homes, into long-term care centers and cancer or heart failure clinics. This allows for appropriate transition to end-of-life care when that makes sense for families. The transition out of the hospital to palliative care provides a safe and dignified way to continue their clinical course, which is a huge challenge.
What educational moves are needed to improve palliative and hospice workforce shortages?
The best way that we can improve the workforce is improving primary hospice and palliative medicine skills, because these are skills that should cross all specialties.
Using emergency medicine as an example; it’s well-known that emergency medicine residents want more training in goals-of-care discussions and feel like that’s something that is missing in their education. Academic centers across the country are trying to integrate and include basic goals-of-care discussions, symptom management and knowledge of hospice into emergency medicine residencies. This goes for surgery residencies also, as well as internal and family medicine and growing fields like anesthesia.
Every specialty has a yearning for some kind of knowledge on how to do this care better, how to be more comfortable doing it. It’s not just specialty training, but really generalized information and skills that can be brought to each specialty. That is the most important thing as we think about the need for nurses, nurse practitioners, physician assistants, social workers and case managers. That multidisciplinary team brings excellent hospice and palliative skills to the table and allows more people to be trained when it’s so critical for more and more patients.
