PURPOSE:In 2020, the University of Colorado School of Medicine launched the Community Hospice and Palliative Medicine (CHPM) Fellowship, a part-time, innovative, online fellowship for midcareer physicians. The 3- to 4-year specialty training program, which includes completing a master of science in palliative care, was created to address the increasing need for palliative care physicians in communities with underdeveloped hospice and palliative medicine resources. This model enables fellows to remain in their communities and clinical practices while completing training leading to board certification. Guided by the Kirkpatrick Model, this program evaluation examined the fellows' perceptions of the program's effectiveness as a training model. METHOD:In 2023, 10 CHPM Fellowship graduates from the first 2 cohorts were invited to participate in recorded video interviews. Using a deductive rapid qualitative approach informed by the Kirkpatrick Model, investigators analyzed interview data across 4 levels of educational impact: satisfaction, learning, behavior, and results. RESULTS:Ten graduates were interviewed. Feedback was relevant to all 4 Kirkpatrick Model levels, including program impacts on system changes, typically a challenging level to document. Four major themes emerged: developing self, being in community, feeling confident and competent, and facing challenges. Subthemes highlighted graduates' perceptions of being a palliative care role model and leader, experiencing personal and professional transformation, establishing supportive relationships, feeling supported by interdisciplinary faculty, and mastering diverse palliative care skills. Participants commented on the program's rigor and offered suggestions for including interdisciplinary faculty members in seminars, increasing business and program leadership content, and increasing administrative support. CONCLUSIONS:The CHPM Fellowship demonstrates a promising model for addressing the national palliative care workforce shortage by providing accessible, community-based training for midcareer physicians. As more physicians complete the program and are board eligible, continued evaluation will be important to update content, guide programmatic changes, and improve the online model.

Background: Predictive health services modeling signals a shortage of board-certified Hospice and Palliative Medicine (HPM) physicians. Methods: This article introduces the Community Hospice and Palliative Medicine (CHPM) Fellowship, an Accreditation Council for Graduate Medical Education (ACGME) Advancing Innovation in Residency Education (AIRE) project designed to enable mid-career physicians (at least five years out from residency or fellowship) to achieve eligibility for board certification in HPM. Results: From 2020 to 2023, 24 fellows have completed or are currently participating in the CHPM fellowship which is evaluated using the Kirkpatrick model. Conclusion: This program shows promise in addressing the impending HPM workforce shortage by allowing physicians to complete a fellowship in their local communities.

Introduction: Moral distress is a commonly recognized phenomenon among health care providers; however, the experience of moral distress by staff caring for patients who die during an acute care hospital stay has not been previously examined. It also remains unclear how the quality of a death may impact moral distress among these providers. Objectives: We sought to understand levels of moral distress experienced by intern physicians and nurses who provided care during a patient's final 48 hours of life, and how the perceived quality of death impacted moral distress. Materials and Methods: We utilized a mixed-method prospective cohort design, surveying nurses and interns following inpatient hospital deaths at an academic safety-net hospital in the United States. Participants completed surveys and answered open-ended questions to evaluate moral distress and the quality of the patient's death. Results: A total of 126 surveys were sent to nurses and interns caring for 35 patients who died, with 46 surveys completed. Overall moderate-to-high levels of moral distress were identified among participants, and we found that higher levels of moral distress correlated with lower perceived quality of death. We identified five themes in our qualitative analysis highlighting the challenges nurses and interns face in end-of-life care, including the following: poor communication, unexpected deaths, patient suffering, resource limitations, and failure to prioritize a patient's wishes or best interests. Conclusions: Nurses and interns experience moderate-to-high levels of moral distress when caring for dying patients. Lower quality of end-of-life care is associated with higher levels of moral distress.

institutions do not incorporate palliative care training in their medical school or residency curricula.In this concurrent session, we will describe a novel palliative care educational intervention at Morehouse School of Medicine, Howard University, and the University of Puerto Rico.During our discussion, we will describe the 2-year ExPERT program educational intervention, site visits to partnering schools, and virtual palliative care workshops with trainees.We will discuss lessons learned from our institutional collaboration to enhance palliative care training at these schools.We will also develop a list of action items that palliative care programs could use to expand this educational intervention to other HBCUs and predominantly Latino-serving institutions.

The demand for specialist palliative medicine physicians, advanced practice providers, and other team members outstrips supply. Traditional paths to specialty practice will not meet projected need. Therefore, innovation and research are required. One innovation is the training of midcareer professionals; those who have been in practice and want to change to palliative care. Barriers to leaving practice and returning to traditional training are high; not the least of which is the opportunity cost. In this roundtable, experts discuss what they have learned from current research, and point the way to additional needed research.

Purpose: To explore how families respond to the death and dying of their loved ones in a hospital setting, archival research was conducted using eight qualitative articles describing next-of-kins’ perceptions of end-of-life care in Veterans Affairs Medical Centers (VAMCs). The articles were based on the qualitative arm of the VA Health Services Research and Development (HSR&D) study entitled, “Best Practices for End-of-life Care and Comfort Care Order Sets for our Nation’s Veterans” (BEACON).Design: The archival research consisted of an interactive methodological process of data immersion, analysis, and interpretation which resulted in the emergence of two overarching thematic frameworks called “losing control” and “holding on.”Findings: “Losing control” is the process that occurs when the patient experiences a cascading sequence of deleterious biological events and situations rendering the caregiver no longer able to direct the timing or setting of the dying trajectory. The notion of “holding on” captures family member’s responses to the need to maintain control after relinquishing the patient’s care to the institutional setting. During the patient’s hospitalization, the dual dynamics of “losing control” and “holding on” unfolded in the spatial, temporal, and life narrative domains.Originality: The findings not only contribute to better overall understanding of family members’ responses to death in the pre-COVID-19 hospital setting but also heighten the awareness of the complex spatial, temporal, and narrative issues faced by family members who lost a hospitalized loved one during the COVID-19 pandemic.

Post-traumatic stress disorder (PTSD) can be exacerbated by subsequent trauma, but it is unclear if symptoms are worsened by impending death. PTSD symptoms, including hyperarousal, negative mood and thoughts, and traumatic re-experiencing, can impact end-of-life symptoms, including pain, mood, and poor sleep. Thus, increased symptoms may lead to increased end-of-life healthcare utilization. To determine if veterans with PTSD have increased end-of-life healthcare utilization or medication use and to examine predictors of medication administration. Secondary analysis of a stepped-wedge design implementation trial to improve end-of-life care for Veterans Affairs (VA) inpatients. Outcome variables were collected via direct chart review. Analyses included hierarchical, generalized estimating equation models, clustered by medical center. Veterans, inpatient at one of six VA facilities, dying between 2005 and 2011. Emergency room (ER) visits, hospitalizations, and medication administration in the last 7 days of life. Of 5341 veterans, 468 (8.76%) had PTSD. Of those, 21.4% (100/468) had major depression and 36.5% (171/468) had anxiety. Veterans with PTSD were younger (mean age 65.4 PTSD, 70.5 no PTSD, p < 0.0001) and had more VA hospitalizations and ER visits in the last 12 months of life (admissions: PTSD 2.8, no PTSD 2.4, p < 0.0001; ER visits: 3.2 vs 2.5, p < 0.0001). PTSD was associated with antipsychotic administration (OR 1.52, 95% CI 1.06–2.18). Major depression (333/5341, 6.2%) was associated with opioid administration (OR 1.348, 95% CI 1.129–1.609) and benzodiazepines (OR 1.489, 95% CI 1.141–1.943). Anxiety disorders (778/5341, 14.6%) were only associated with benzodiazepines (OR 1.598, 95% CI 1.194–2.138). PTSD’s association with increased end-of-life healthcare utilization and increased antipsychotic administration in the final days of life suggests increased symptom burden and potential for terminal delirium in individuals with PTSD. Understanding the burden of psychiatric illness and potential risks for delirium may facilitate the end-of-life care for these patients. NCT00234286

Background: Widespread community engagement in advance care planning (ACP) is needed to overcome barriers to ACP implementation. Objective: Develop, implement, and evaluate a model for community-based ACP in rural populations with low English language fluency and health care access using lay patient navigators. Design: A statewide initiative to improve ACP setting/subjects-trained in a group session approach, bilingual patient navigators facilitated 1-hour English and Spanish ACP sessions discussing concerns about choosing a surrogate decision maker and completing an advance directive (AD). Participants received bilingual informational materials, including Frequently Asked Questions, an AD in English or Spanish, and Goal Setting worksheet. Measurement: Participants completed a program evaluation and 4-item ACP Engagement Survey (ACP-4) postsession. Results: For 18 months, 74 ACP sessions engaged 1034 participants in urban, rural, and frontier areas of the state; 39% were ethnically diverse, 69% female. A nurse or physician co-facilitated 49% of sessions. Forty-seven percent of participants completed an ACP-4 with 29% planning to name a decision maker in the next 6 months and 21% in the next 30 days; 31% were ready to complete an AD in the next 6 months and 22% in the next 30 days. Evaluations showed 98% were satisfied with sessions. Thematic analysis of interviews with facilitators highlighted barriers to delivering an ACP community-based initiative, strategies used to build community buy-in and engagement, and ways success was measured. Conclusion: Patient navigators effectively engaged underserved and ethnically diverse rural populations in community-based settings. This model can be adapted to improve ACP in other underserved populations.

•Explain the purpose, content and methods of the BEACON II educational intervention.•Describe the PPCT team members perspectives on the processes shaping implementation the CCOS in VA Medical Centers.•Recognize the need for novel approaches to the integration of palliative care initiatives in acute care settings of VA Medical Centers. Best Practices for End-of-Life Care for our Nation's Veterans (BEACON II) delivered a Comfort Care Education Intervention leveraging the established infrastructure of VA Palliative Care Consult Teams (PCCT) to facilitate activation of a Comfort Care Order Set (CCOS) and education of non-palliative providers in primary palliative care in acute care settings. During the 4-month implementation window, PCCTs were charged with training providers and developing plans to sustain training. To explore PCCT members' perspectives on the CCOS implementation/education process. 132 PCCT members from 46 VAMCs received training in the CCOS, and 78 individuals participated in post-training telephone interviews. Qualitative analysis identified underlying dynamics shaping participants' perceptions of the CCOS implementation/education process. Established practice patterns impeded CCOS dissemination in acute care settings. PCCT members articulated distinctions between CCOS-receptive and CCOS-resistant service lines, opting to systematize the CCOS in inpatient hospice or long-term care (CLC) units, while taking “baby steps” to familiarize acute care providers on a case-by-case basis. PCCT members described a tension between the ascribed role of consult team and the acquired role of CCOS training team, distinguishing between acute care practitioners who value PCCT-provided palliative care and acute care practitioners who prefer to provide palliative care themselves. Training strategies targeting internal medicine residents emerged as a promising approach to enhancing CCOS dissemination. The established infrastructure of VAMC PCCTs may not suffice for implementing education programs to disseminate primary palliative care and a CCOS in acute care settings. Overcoming barriers to dissemination of palliative care education in acute care settings should consider additional training mechanisms for bypassing obstacles embedded in practice patterns and service lines.

A growing body of research has examined modalities for delivering palliative care education; however, we know little about education and training preferences of VA interdisciplinary Palliative Care Consult Teams (PCCT). In the BEACON II study, we explored training preferences of PCCTs from 46 Veterans Affairs Medical Centers (VAMCs) participating in either a multisite webinar or a small group, in-person workshop. We interviewed participants by telephone seven to eight month post-training. In all, 75.9% preferred in-person education and training, including 78.9% of workshop participants and 73.1% of webinar participants. Respondents described in-person training as fostering learning through the following processes: (1) active engagement and focus, (2) interaction and networking, (3) meaning-making and relevance, and (4) reciprocity and commitment. Although it is not possible for Web-based palliative care education programs to replicate all aspects of the in-person learning experience, building experiential, interactive, meaningful, and reciprocal components into Web-based education may help shift preferences and make interdisciplinary team-based palliative care education accessible to a larger audience.

•Explain the role of the ACGME in supporting innovation, and describe recent innovations within HPM training.•Assess opportunities for and barriers to potential training innovations within your own institution.•Understand unique generational characteristics, and learn strategies for bridging generational divides. HPM fellowships will need to evolve and innovate to meet the needs of our growing field, its heterogeneous trainees, and our multigenerational learners. The fellowship directors' preconference will help participants draw inspiration from examples of innovation within the HPM fellowship community, and learn how the ACGME can support such innovations from a senior member of its executive staff. The session will also include a workshop on strategies for effective intergenerational communication. This year's program will begin with a description of innovations supported by the ACGME. This will be followed by brief presentations from fellowship colleagues describing innovations in interprofessional and part-time training, as well as pilot projects to create more flexible fellowships for mid-career and distance learners. Following these presentations, break-out groups will explore each participant's opportunities, barriers, and assessment methods for potential innovation. The participants will then share lessons learned and reflect on what palliative care training may look like in the future. In the multigenerational communication workshop, participants will discuss experiences and challenges that they may be facing and explore potential methods to address these challenges. Participants will leave with relevant practical skills in intergenerational communication. By the end of this half-day, participants will have developed tools to approach the next generation of fellowship training.

Background: Palliative care (PC) is a limited resource in health care systems. Many providers develop a PC interest later in their careers when it is difficult to relocate and compete for a limited number of training positions. In communities without an academic tertiary medical center, interprofessional PC community specialists are poised to deliver high-quality accessible PC to patients/families with needs beyond what can be addressed by primary care providers. Objective: An interprofessional 36-credit Master of Science in Palliative Care (MSPC) provides evidence-based education to nurses, pharmacists, physicians, physician assistants, social workers, spiritual care providers, psychologists, counselors, and other allied health professionals. Design: The predominantly online curriculum, designed and taught by an interprofessional faculty, focuses on interdisciplinary teamwork, communication skills, and practical application of biomedical and psycho-sociocultural-spiritual-ethics content. The pedagogy is narrative based, emulating in-person clinical experiences, with patient cases progressing throughout the curriculum. We have enrolled four student cohorts. Measurements: Student self-assessments pre-mid-post program. Results: Students highly rate curriculum with demonstrated application of knowledge in case integration assignments, simulations with standardized patients, and Capstone Projects. Students' self-assessed skills on a 39-item scale increased on average to the highest level of 5 (able to perform independently and teach others). Conclusions: The inaugural student cohort reports high levels of engagement and satisfaction, including mastery and synthesis of didactic and experiential content through case integration projects. Students who worked in PC/hospice settings have advanced in their professions; others have transitioned to PC work. The MSPC has capacity to meet projected PC workforce gaps.

•Describe potential differences between patients with and without PTSD at the end of life.•Consider how these findings may relate to caring for patients with PTSD at end of life. The effects of PTSD on the end of life are not well studied. PTSD is a symptomatic illness, affecting pain sensation, anxiety, and sleep. High symptom burden, reliance on avoidant coping strategies, and high comorbid substance use in PTSD, all suggest that these patients may have a more complicated end-of-life trajectory. To conduct an exploratory descriptive analysis of end-of-life care for veterans with and without PTSD dying in VA hospitals. This was a secondary analysis of a multiple-baseline, stepped-wedge design implementation trial to improve end-of-life care processes for VA inpatients. Variables were collected via direct chart review, using a chart abstraction form. Inter-rater reliability was good to excellent. Analysis included descriptive statistics and chi-square analyses with Bonferroni correction. PTSD was present in 8.76% of the sample (468/5341). The PTSD population was 98.7% male and 36.5% Black (171/468), with a younger mean age at death than those without PTSD (PTSD 65.4, no PTSD 70.5, p<0.0001). Patients with PTSD had higher mean VA hospital admissions and emergency room (ER) visits in the last 12 months of life (admissions: PTSD 2.8, No PTSD 2.4, p<0.0001; ER visits: 3.2, 2.5, p<0.0001). During the final hospitalization, patients with PTSD had higher rates of intensive care unit (ICU) use (49.6%, 42.7%, p=0.0041) and higher rates of advanced directives (48.1%, 37.9%, p<0.0001), trending toward lower rates of do-not-resuscitate status (66.5%, 71.0%, p=0.037). In the last 7 days of life, patients with PTSD had higher rates of receiving benzodiazepines (47.4%, 39.7%, p=0.0012) and antipsychotics (26.3%, 15.7%, p<0.001), trending toward higher receipt of opiates (73.3%, 68.3%, p=0.026). Veterans with PTSD dying in VA hospitals appear to experience differences in end-of-life care, compared to those without PTSD.

•Develop an effective model for community-based advance care planning activity in rural Colorado populations facing traditional barriers created by low rates of English language fluency and healthcare access.•Adapt, refine, and evaluate a program that can be implemented in other community settings and underserved populations. Widespread community engagement in advance care planning (ACP) is achievable in community settings through multi-faceted approaches, as supported by implementation literature. To adapt an ACP group visit model to increase ACP engagement in rural underserved Colorado communities. Our statewide rural initiative utilizes patient navigators (PNs) to facilitate ACP conversations in churches, libraries, schools, businesses, nursing homes, clinics, local government districts, and area health education centers. Two bilingual lay PNs trained in an ACP group session framework facilitated one-hour English and Spanish sessions in a comfortable, confidential space. Participants receive bilingual informational materials including Frequently Asked Questions, an easy-to-read Advance Directive (AD) (www.prepareforyourcare.org), and goal setting worksheets. Participants are encouraged to discuss their understanding and concerns about choosing a medical decision maker and completing a comprehensive AD. Participants are invited to complete the ACP Engagement survey (ACP-4) immediately post session. To date, we conducted 67 community-based sessions engaging 929 participants; 64.6% female, 42% ethnically diverse. Post session ACP-4 (51% response rate) showed 28% planned on naming a decision maker in the next 6 months and 22% in the next 30 days; 25% were ready to talk about future healthcare decisions with their decision maker in the next 6 months and 22% in the next 30 days; 31% were ready to talk to their provider about healthcare preferences in the next 6 months and 16% in the next 30 days; 31% were ready to complete an AD in the next 6 months and 23% in the next 30 days. Evaluations showed 56% were extremely satisfied, 43% were satisfied, with 98% reporting the session was the right length of time. PNs effectively engaged underserved and ethnically diverse rural Colorado populations in community-based settings. Our model can be readily adapted by other healthcare settings to improve ACP in underserved populations.

•Compare and contrast profession-specific palliative care competencies.•Participate in the final round of a Delphi process and provide feedback and comments on proposed standards for program quality for post-licensure interprofessional palliative care education.•Describe three models of post-licensure interprofessional palliative care education. Most currently practicing clinicians have no formalized palliative care (PC) education. The Joint Commission and National Academy of Medicine recognize the need for PC across care settings. Some university-based educators are developing educational programs for both clinicians and current students to meet the PC workforce shortage; however, most PC education has been developed for a specific discipline. PC is a team specialty; therefore, education with other professions on the PC team is an important part of practice preparation. We are using a Delphi process to develop consensus among interprofessional PC educators and clinicians in the following areas: 1) optimal PC post-licensure educational program characteristics and curriculum components; 2) definitions of key terms; and 3) criteria, standards, and evaluation for quality PC educational programs. Standards for program quality and consistency will be published and may be used to inform a voluntary program recognition process for endorsement of excellence for post-licensure PC interprofessional education. Through a needs assessment, PC competencies for each core profession were compared to the National Consensus Project for Quality Palliative Care guidelines. In 2017 at the AAHPM/HPNA assembly, an interprofessional steering committee of educators, who have already developed interprofessional PC educational programs specifically for practicing clinicians, met to begin the process of developing criteria and standards for quality interprofessional PC programs. All participants provided suggestions for overall categories that were then refined. Educators and clinicians representing the core professions of PC education and practice were then engaged in a Delphi process to refine the categories and develop sub-criteria and definitions. These categories, criteria, and definitions will be presented during this session with an opportunity for further discussion and input from assembly attendees. We will also use three current programs as examples on how these criteria are being implemented.

•Expose attendees to how next-of-kin become aware of the emergence of life-limiting illness and keep track of its progression outside of the clinical setting.•Engage the attendee in a discussion of the implications of the lay perspective for informing the clinical perspective on the trajectory of life-limiting illness. The clinical perspective on the trajectory of life-limiting illness is well documented. However, we know far less about how next-of-kin become aware of and keep track of changes in a patient's condition outside of the clinical setting. The purpose of this qualitative analysis was to explore next-of-kin’s characterizations of the emergence and progression of a Veteran’s life-limiting illness. Using a phenomenological perspective, we conducted a secondary analysis of face-to-face interviews with 78 next-of-kin of deceased Veterans. Next-of-kin relied on personal observations grounded in everyday life to mark the emergence and progression of the Veteran’s illness. Observations were anchored in specific timeframes and situated in particular places and events. “Turning points” and “markers of decline” were salient constructs in next-of-kin’s accounts, bringing to mind details of the “when’s” and” where’s” awareness of life-limiting illness emerged. Turning points and markers of decline served as signals and signposts, representing a line of demarcation after which the Veteran’s health never was the same. Lay awareness of the Veteran’s worsening condition often preceded clinical documentation. Next-of-kin recalled the emergence and progression of a Veteran’s life-limiting illness as part of a larger narrative of the patient’s life. Awareness of declining health was embedded in the spatial-temporal contexts of everyday life and typified as turning points and markers of decline.