Monday, November 27, 2017

Documentation Design: Palliative Care Notes in the EHR Era

by April Krutka (@April918) and Christian Sinclair (@ctsinclair)

DOCUMENTATION...who knew this one word could provoke so many emotions among health care clinicians? Say this word, and you will hear stories of triumph and defeat. From universal required elements in the admission history and physical, progress notes and discharge summaries to the specialty specific language of advance care planning and pain assessments, there is a constant pressure to get all the pieces to fit correctly. Moving from analog to digital offered much hope, but also new problems. Before we even start typing or dictating a new note, most of the success or failure lies in how we design our notes from the start.

Standardized documentation promises clinicians consistency, data tracking, opportunities for quality improvement, and inclusion of essential elements of a specialty. If a template is built well, it should save time and impact the clinician experience and patient care in a meaningful way. Designing templates can be like walking a tight rope. Fall on either side, and it can lead to burnout and frustration by those using the templates.

There are many stakeholders who have a vested interest in the components of a clinical note. It is used by many different entities for different reasons: the billing department wants to submit the correct bill, the clinician/team needs to communicate clinical plans, the patient wants to be assessed accurately and without stigma, payors want to make sure they are paying for value, risk management stresses timeliness and compliance, health care administration wants to make sure all of the above are being done well. We are asking a lot of our notes and the templates that guide them. And for tools like these that are used millions of times daily, there is not much research or quality assessment involved in these vital communication platforms.

Palliative care documentation and templates also present unique challenges, as palliative care is provided in an interdisciplinary setting, tells personal story outside of standard medical issues and must relay the overriding goals that drive the creation of a medical plan. If we are successful, we are able to tell a human story, effortlessly meet billing standards, communicate seamlessly with all parties involved, save time, and track the spectrum of suffering or comfort and quality metrics.

This is the first of many posts over the next few months as we prepare for our presentation "Documentation Design: Palliative Care Notes in the EHR Era" in Boston at the Annual Assembly of Hospice and Palliative Care in March 2018. (Psst it is Friday, Mar 16th at 3pm, make sure you come!) We are very interested in hearing about your challenges and successes!

We are kicking it off with a #hpm chat, Wednesday Nov 29, 2017 at 9p ET/6p PT. We will post here and on the AAHPM Connect Forum to seek your input to help make our talk meet your needs. (Sign up on hpmchat.org to get alerts to upcoming chats!) Topics we will be covering in the chat include: Templates: love them, hate them, what works best for you? Should we consider different types of notes for different reasons or make them all try in fit in our usual current note types? How can we make the EHR work for us and not the other way around?

April Krutka is a palliative care physician at Intermountain Healthcare in Utah working on the Cerner EHR. Christian Sinclair is a palliative care physician at the University of Kansas Health System working on the EPIC platform.

Monday, November 27, 2017 by Christian Sinclair ·

Monday, November 13, 2017

LGBTQ at the End-of-Life: Needs and Challenges

By Vivian Lam

Holistic care is essential in the mission to fully meet a patient's needs. And a holistic perspective is the backbone of end of life and palliative care--it's the basis of having an interprofessional team that acknowledges that quality of life is multifaceted, and lives are diverse. But getting to know a patient enough to be able to be "holistic" can be difficult. And in the case of LGBTQ individuals, getting to know the patient as a whole is not only all the more important—it’s integral.

According to a 2016 Gallup survey, 4.1% of U.S. adults openly identify as LGBTQ, or around 10 million adults. Of that 4.1%, 2.4% are Baby Boomers (born 1945 to 1964), and 1.4% Traditionalists (born 1913-1945). And in order to be able to provide holistic care to LGBTQ patients, it’s important to recognize that LGBTQ individuals have specific medical, psychological, and social needs. They are more likely to experience mental health problems, due to a number of social stressors including prejudice, stigmatization, anti-gay violence, and internalized homophobia. Many are susceptible to depression, suicide, and substance abuse. And many face isolation, and difficulty accessing resources and appropriate care.

On the flipside, LGBTQ individuals are more likely to have an advance directive completed as a legal safeguard to their wishes, and are likely to have “chosen” or “lavender” families and strong community ties, and highlight the importance of including these individuals in developing a support system.

To begin to provide holistic care to LGBTQ patients, it is important to have basic cultural competency on LGBTQ people and their historical and contemporary experiences in healthcare. Though some strides have been made in incorporating LGBTQ cultural competency in healthcare training, much can be done in executing these findings in practice.  And it is very important to remember that small steps can quickly translate into big steps—starting with the basic challenges that LGBTQ patients face at the end-of-life.

Anticipating discrimination, and going “back into the closet”

Though strides have been made in fostering acceptance of and earning equal rights for the LGBTQ people, historical trauma and ongoing discrimination strongly color LGBTQ lives today. And for LGBTQ elders who lived in a period of less social acceptance, and harbor a lifetime of discrimination and negative healthcare experiences, an expectation of prejudice on the basis of their sexuality may not only detract from holistic care, but also prevent them from obtaining care in the first place.

Some feel that hospice and palliative care are not services available that are available to them, and will not understand or meet their needs as they relate to sexual orientation or gender identity. Some anticipate receiving worse treatment than their straight and gender-conforming peers. And some feel that they must go “back into the closet” in order to protect themselves from the hostility of hospital or assisted living staff and patients. And transgender individuals’ wishes to be recognized and die as their preferred gender are often disrespected.

Disclosure of sexual and gender identity can aid in providing sensitive and appropriate care, and augment the patient-provider relationship. It can also help identify potential challenges and ways to better support a patient and their loved ones. Though disclosure is ultimately up to the patient, providers need to actively foster an environment where the patien
t feels comfortable enough to disclose their identity.

Best practices for creating a safe space:

  • Place a sign that signals that your office is LGBTQ-friendly, and display brochures that are relevant to LGBTQ-health issues.
  • Review your literature and forms to ensure they have inclusive language and questions.  Add a transgender option alongside “male/female” in your intake forms.
  • Do not assume a patient’s sexuality or gender identity, and do not force a patient to disclose their sexual or gender identity if they are uncomfortable. Instead, introduce yourself with your preferred pronouns, and ask about theirs. Do not assume that a trans patient desires or has undergone surgical or hormonal transition. Make it clear that you are comfortable with their identity, and are willing to learn how to support them through identity-specific issues.
  • Try having a conversation, if they are comfortable, about their fears and needs. Be aware of the language you use, and ask about their preferred name and gender pronouns.

Ask questions like:
“Who are the most important people in your life?”
“Do you have a significant other?”
“Are you in a relationship?”
“Do you live with anyone?”
“Tell me more about yourself?”

Family, bereavement, and legal challenges

Isolation and “non-traditional” family status factor greatly in the delivery and facilitation of care. LGBTQ individuals are more likely to be single, less likely to have children, and more likely to be estranged from their birth families. Many have “families of choice” (also called “lavender families”), composed of close friends and support groups. But for many LGBTQ elders, these chosen families may be threatened by aging and illness, and face trauma from loss in the HIV epidemic in the 1980s and 1990s.

Many feel concern that their partner might not be recognized or be able to serve as their durable power of attorney for medical and end-of-life decision-making. Those without a legal partner or paperwork specifying their wishes face having family members they may not have spoken to for years making decisions on their behalf. For LGBTQ individuals, having a power of attorney in place is top priority.

And the bereaved are vulnerable to being left out of the picture altogether. Non-registered surviving partners are denied family leave and bereavement benefits, automatic inheritance jointly owned property, and may lose the right to determine funeral plans. Many experience disenfranchised grief by not being recognized as needing support, and often carry a greater care burden due to late access to care.

Best practices:
  • Ask who the most important people in their life are
  • Ensure that their partner is recognized as such and feels supported.
  • If they bring someone into the meeting that they introduce as a close friend but may in fact be their partner, emphasize that you are comfortable with their identity and are willing to support them.
  • Address legal concerns 

 A paucity of research and training

There are large gaps in the literature in regards to providing care for LGBTQ elders. There has been a general “invisibility” of LGBTQ older adults, due to lack of data collection around sexual orientation and gender identity. And most research and much of the data have been based on the experiences of white, middle class to affluent individuals living in urban areas. The majority of the reports and papers found through an online search on LGBTQ end-of-life care was from the UK and Australia.

In order to fully assess and address the issues and needs that LGBTQ individuals face at the end of life, further research must be done. And greater focus must be placed on the diverse range of experiences that make up the community.

Best practices:

  • Make an effort to educate yourself on basic LGBTQ health disparities and terminology, and how to recognize and challenge discriminatory beliefs about LGBTQ people.
  • Implement a staff training program and advocate for cultural competency in treating LGBTQ patients.
  • Encourage further research on the needs and experiences of diverse LGBTQ patients at the end-of-life.

Treating everyone the same is not the same as meeting someone’s needs. It is not so much a matter of providing equal care and avoiding discrimination than recognizing that sexuality and gender can be an important part to someone’s identity, and does impact their health needs.

Making a big impact in the end-of-life and healthcare experiences of LGBTQ patients requires both little and large effort. Providers must have an open mind, be respectful and compassionate, and acknowledge an individual’s unique life from beginning to end—the basic tenets of holistic end-of-life and palliative care.

It’s simple—but it makes all the difference.

Further resources:
National LGBT Health Education Center (Fenway Institute)
National Resource Center on LGBT Aging
SAGE (Services and Advocacy for GLBT Elders)
LGBT HealthLink
     best and promising practices for LGBT cancer patients
LGBTQ -Inclusive Hospice and Palliative Care (Book)
Creating a Welcoming Clinical Environment for LGBT Patients – Rainbow Welcome Initiative
Providing Welcoming Services and Care for LGBT People – Fenway Institute
“Hiding who I am”: The reality of end of life care for LGBT people – Marie Curie
American Academy of Hospice and Palliative Medicine’s video on providing palliative care to LGBT patients
Search engine for agencies trained on LGBT cultural competency – National Resource Center on LGBT Aging

Vivian Lam is a clinical research coordinator in thoracic oncology at UCSF, striving to contribute tangibly to the fields of end of life and palliative care, and the medical humanities. She enjoys running long distance and warbling the same songs in the shower all year long.

Monday, November 13, 2017 by Pallimed Editor ·

Saturday, November 4, 2017

Defining Dignity at End of Life: One Question to Ask Hospice Patients

by Lizzy Miles (@lizzymiles_MSW)

I start every new hospice patient interaction with a hello. I introduce myself and then ask for permission to sit and visit. It is not uncommon for the patient to start off on guard, wary. By the time patients meet me, they have been through a lot of medical interactions. They have been asked a lot of questions.

I tell them I have just one question. I sometimes notice an exhale. Whew. She’s not going to grill me.

Dignity In Care, developed from research by Dr. Harvey Max Chochinov, starts with the Patient Dignity Question (PDQ). It is a simple, open-ended question: “What do I need to know about you as a person to give you the best care possible?”

The answer to this question will lead you to have a greater understanding of the needs, desires and identity of the person beyond their being a “patient.” There is no wrong answer to this question, despite what family members might think.

One time a patient responded with, “I am a lifelong Cubs fan.”


The nurse, chaplain and I made small talk with the patient for a few minutes about baseball, The Cubs, and a broken curse.

The patient’s wife scowled and then apologized to us. “I’m sorry, he gets off track.”

“He’s not off track,” I responded. “This is what’s important to him right now.”

What we weren’t doing was talking about his illness. He was sick of talking about his symptoms, his diagnosis, how he was feeling. For once, he wanted to feel normal.

The answers to “the dignity question” as I call it, are varied, but always telling.

The patient who told me, “I love my husband” would eat when she wasn’t hungry just to appease him.

The patient who said, “I’m precise in my care of things” wanted to know the details of every medication that was being administered.

The patient who said, “I am a good person. I try to help people” worried that every request was an imposition.

I have heard more than one patient say, “I am crazy.” It is their way of sharing that they have a certain approach to life, and they want to keep the conversation light.

One patient I met in the inpatient unit had been throwing up for days. We were having trouble getting her nausea under control. In this midst of vomiting she told me, “I’m happy-go-lucky, hopefully.”

Sometimes the patient does not want to answer the question. They will say, “I don’t know.” Depending on their tone, I might ask, “Would it be safe to say you are a private person?” If they acknowledge that they are private, then I tell them it’s good for me to know that. I explain to them that as their social worker, my number one job is to advocate for them. I tell them I will let others know they don’t want a lot of questions. Not surprisingly, when I give them “permission” to be private, they often do open up to me.

If a patient says, “I don’t know” because they are not introspective or don’t like talking about themselves, I’ll ask if they are okay with me asking their family. This opens up an interesting dialogue where the family shares about the patient in front of them. I will usually ask the patient if they agree with what their family member said.

A daughter once said, “She’s cranky” and suddenly the quiet patient retorted, “look who’s talking!” and they got into a friendly banter.

Families don’t always know how the patient would answer. Whenever possible, get the answer directly from the patient. A patient who was described as “family oriented” later woke up to define himself differently. “I am a musician,” he said.

There are times when a patient comes onto hospice minimally responsive and not able to answer for themselves. The family members’ responses to the dignity question can still be helpful.

I had one spouse who told me that her husband was extraordinarily modest. He didn’t even like to change clothes in front of her. That week, I went to the house when he was actively dying and I noted there were at least 15 people wandering in and out of the room. I provided as much support as I could, and once I was certain symptoms were under control and family felt confident in providing care, I started to say goodbye.

I sat down with the wife on the porch.

“Do you remember when you said your husband was modest?” I asked.

She nodded.

“How do you think he would feel about all the people looking at him while he was dying?”

She knew where I was going with my line of questioning. “Oh he would hate it!”

I agreed and suggested that he might be hanging on until he had privacy. I told her I knew it was a delicate situation because other family needed to say goodbye, and I would leave it up to her to figure out the best way to clear the room.

She reported later that she was able to encourage people to give him privacy, and he died that evening with just her by his side.

FOR YOU

How do you see yourself?  How would you answer the question? How would your loved ones describe you?

I told my husband about the dignity question one evening after work. I said,” I would like to think I’m happy-go-lucky.” He laughed loudly (perhaps snorted) and told me I was most definitely NOT a carefree person.

I sometimes share this story with families as a way to encourage them to imagine what the patient would want me to know (if the patient can’t speak for themselves). The question itself appears to be therapeutic as loved ones speculate how the patient would describe themselves. If multiple loved ones are in the room together, I give everyone the opportunity to answer the question and you learn about the patient and their relationship.

“He was always generous.”

“She is a gentle spirit.”

“He would give you the shirt off his back.”

“She liked strippers, booze and rock and roll.”

The way that patients define dignity is unique to the individual. If you are not familiar with Dignity In Care research, I would highly recommend the Dignity In Care website which has information on research effectiveness and an additional toolkit of questions to further explore patient needs.

Lizzy Miles, MA, MSW, LSW is still trying to figure out how she needs to project a happy-go-lucky vibe. She is a hospice social worker in Columbus, Ohio and regular contributor to Pallimed.org. Lizzy authored a book of happy hospice stories: Somewhere In Between: The Hokey Pokey, Chocolate Cake and the Shared Death Experience. Lizzy is best known for bringing the Death Cafe concept to the United States. You can find her on Twitter @LizzyMiles_MSW.

Memes created by author utilizing photos from unsplash.com
sunflowers: Brigitte Tohm
baseball: Joey Kyber
precise:  Andrea Sonda
musician: Junior Pereira


Saturday, November 4, 2017 by Lizzy Miles ·

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