state of the division: an update on the past, present & future of the division of palliative...
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STATE OF THE DIVISION:An Update on the past, present & future of the DIVISION OF PALLIATIVE CARE
Jeff Myers MD, CCFP, MSEdW. Gifford-Jones Professorship in Pain and Palliative CareHead and Associate Professor - Division of Palliative Care, Department of Family and Community MedicineFaculty of Medicine, University of Toronto
DPC Grand Rounds June 14, 2012
DIVISION OF PALLIATIVE CARE
Who are we?
What does being a DPC Member mean?
What do we do?
Why do we matter?
Where are we going?
How will we get there?
What can each of us do?
DPC: WHO ARE WE?
“The core purpose of the DPC is to create and support a community of learners, teachers, innovators, researchers and practitioners working together to improve the quality of palliative and end of life care for patients and their families.”
DPC Strategic Plan, 2009
The values serving to guide
all DPC activities are:
Interprofessionalism
Community
Innovation
Advocacy
DPC Strategic Plan, 2009
DPC: WHO ARE WE?
The largest academic palliative care division in Canada!!!
DPC: WHO ARE WE?
2002: Residency Program
2007: Formal status as an academic Division (Head, Dr. Larry Librach, 2007-11)
2009: Inaugural Strategic Plan: Long Term Vision
Every health care professional trained through the U of T will be able to
demonstrate basic competencies in the provision of quality palliative and EOL care
DPC will be a leader in developing, measuring and teaching advanced
competencies in palliative care in Canada
DPC: WHO ARE WE?
Long Term Vision
A robust and collaborative research program will be credited with discoveries that challenge current best practice in care provision and
education and explore innovative interventions that improve the quality of palliative and EOL care
Professionals seeking a location for clinical practice, research and/or education in palliative care within an expansive, dynamic environment
will choose Toronto and the DFCM’s DPC
DPC: WHO ARE WE?
DPC: ORG STRUCTURE
DPC: COMMITTEE LEADS
CPD Lead: Monica Branigan
RPD: Giovanna Sirianni
Interim RPD: James Downar
Education Co-Leads: Anita Chakraborty & Monica Branigan
Research Co-Leads: Amna Husain & Paolo Mazzotta
Admin Lead: Heather Huckfield
DPC: PROFESSION / DISCIPLINE LEADS
Social Work: Susan Blacker
Nursing: Sharon Reynolds
Pediatrics: Adam Rapaport
DPC: SITE REPS
Baycrest: Daphna Grossman
CVH: Manisha Sharma
Markham Stouffville: Gina Yip
Mt Sinai: Russell Goldman
NYGH: Niren Shetty
PMH: Julia Ridley
Scarborough: Larry Zoberman
SickKids: Adam Rapaport
DPC: SITE REPS
Southlake: Cindy So
St. Joseph’s: Carol Hughes
St. Michael’s: Ignazio LaDelfa
Sunnybrook: Dori Seccareccia
TEGH: Kevin Workentin
TGH/TWH: Sharon Reynolds
Trillium: Tony Hung
DPC: MEMBERS
Membership Assembly
Current composition:
Over 60 Faculty Members
Over 60 Associate Members
FACULTY MEMBERS
Clinicians who have pursued and achieved a U of T faculty appointment
Available to all professionals who are members of a U of T affiliated institution and actively involved in palliative care and teaching, education, research, creative professional activity and/or leadership
DPC: WHAT DOES BEING A MEMBER MEAN?
ASSOCIATE MEMBERS
Clinicians without a formal clinical or faculty appointment with the U of T who have an interest and/or a clinical practice involving palliative care
DPC: WHAT DOES BEING A MEMBER MEAN?
DPC MEMBERSHIP: WHY?
• Participate in DPC related activities, initiatives and committees (eg. PD, teaching/education, research, clinical, operations, administrative, social networking)
• Contribute to building a sense of academic community • Be informed about DPC related activities and initiatives• Connect/collaborate with colleagues across the DPC• Cultivate a profession specific community • Gain exposure to and develop skills related to
professional and/or academic activities• Collaborate on profession specific projects/initiatives• Opportunities to explore formal and informal mentorship
WHAT DO WE DO?
DIVISION OF PALLIATIVE CARE
We Educate
95% of DPC Members are involved in teaching and
education activities
DPC: WHAT DO WE DO?
Undergraduate MedicinePre-clerkship:
“Pain Week”; MMMD course “Approaching End Of Life”; ASCM
Clerkship:
Anesthesia, General Surgery, Family Medicine, Transition to Residency, FMLE
DPC: WHAT DO WE DO?
Postgraduate Medicine
DPC: WHAT DO WE DO?
Postgraduate Medicine: Enhanced Skills
• Clinical Palliative Care Enhanced Skills Program
St. Joseph’s Health Centre Site
12 graduates since 2005
North York General Hospital Site*
• Conjoint Palliative Medicine Residency Program*Recently implemented
DPC: WHAT DO WE DO?
CONJOINT RESIDENCY PROGRAM
Annual Growth in # of Positions and Applicants
CONJOINT RESIDENCY PROGRAM:GRADUATES
DPC: WHAT DO WE DO?
CE & PD
We Educate - Innovations• Centre for IPE - Case Based Session• PGCoreEd• Social Work Interest Group - Susan Blacker• National Learner Assessment Collaborative• CVH/Trillium - collaboration with FHT (LEAP)• Collaboration with Cicely Saunders Institute:
Medical Student Exchange Fellowship (Dr. Robert Buckman)
DPC: WHAT DO WE DO?
We Discover
Over 50 publications in last five years
Dr. Amna Husain PI for CIHR Grant: Ranked #1
DPC: WHAT DO WE DO?
A few examples…
DPC: WHAT DO WE DO?
A few examples…
DPC: WHAT DO WE DO?
We Are Acknowledged2011 Undergraduate New Teacher Award: Dr. Jean Hudson
2010 Helen P. Batty Award: Dr. James Meuser
2010 DFCM Awards of Excellence: Dr. Monica Branigan
2010 PD Program Excellence Award: Dr. Kevin Workentin
2010 PD Program: Dr. Pauline Abrahams
2009 John W. Bradley Educational Admin: Dr. Dori Seccareccia
2009 Postgraduate Education Program: Dr. Leah Steinberg
A few examples…
DPC: WHAT DO WE DO?
We Are Acknowledged
Senior Promotion to the Rank of Associate Professor:
2012: Dr. Albert Kirsen & Dr. Vince Maida
2011: Dr. Monica Branigan, Dr. Amna Husain & Dr. Jeff Myers
2010: Dr. Jamie Meuser
A few examples…
DPC: WHAT DO WE DO?
WHY DO WE MATTER?
DIVISION OF PALLIATIVE CARE
DPC: WHY DO WE MATTER?
The MOH says so…
The care we provide makes a difference…
DPC: WHY DO WE MATTER?
We are catching on in other settings…
DPC: WHY DO WE MATTER?
Conclusions:
“Our prospective study shows that dementia is a terminal illness and furthers our knowledge of the clinical complications characterizing its final stage.”
This was the first time this statement was made
We are catching on in other settings…
DPC: WHY DO WE MATTER?
“Classifying all seniors affected by advanced dementia as terminally ill…can become a
gateway to therapeutic neglect."
CLINICAL COURSE – DEMENTIALETTER TO THE EDITOR
We are catching on in other settings…and familiar challenges lie ahead
DPC: WHY DO WE MATTER?
A request was recently made of me to speak to the topic:
“How to initiate and have end-of-life discussions in the office for patients with palliative conditions?“
DPC: WHY DO WE MATTER?
A request was recently made of me to speak to the topic:
“How to initiate and have end-of-life discussions in the office for patients with palliative conditions?“
How might this be more precisely worded?
DPC: WHY DO WE MATTER?
A request was recently made of me to speak to the topic:
“How to initiate and have goals of care discussions in the office for patients with advanced and/or incurable“
DPC: WHY DO WE MATTER?
A request was recently made of me to speak to the topic:
“How to initiate and have goals of care discussions in the office for patients with advanced and/or incurable“
Propose this to be a primary solution to effectively addressing the “tsunami of chronic disease”
DPC: WHY DO WE MATTER?
1996-97
1997-98
1998-99
1999-00
2000-01
2001-02
2002-03
2003-04
2004-05
2005-06
2006-07
2007-08
2009/2010
2010/2011
2011/2012
2012/2013
2013/2014
2014/2015
2015/2016
2016/2017
2017/2018
2018/2019
2019/2020
2020/2021
2021/2022
2022/2023
2023/2024
2024/2025
2025/2026
2026/2027
2027/2028
2028/2029
2029/2030
2030/2031
2031/2032
2032/2033
2033/2034
2034/2035
2035/2036
0
20
40
60
80
100
120
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80 80 80 81 81 81 83 84 85 84 8689
92 94 96 98 100102104106108110112114116118120122124127129131134137
140143
145148
152
Num
ber
of D
eath
s (1
000'
s)
Total Number of Deaths projected to increase: By 20% in 10 years from 2010-11 to 2020-21. By 65% in 25 years from 2010-11 to 2035-36.
Actual and Projected Deaths in Ontario: 1996-2036
WE ARE HERE!!!
WHERE ARE WE GOING?
DIVISION OF PALLIATIVE CARE
SUB-SPECIALTY STATUS• Currently, the RCPSC application process for
formal recognition of Palliative Medicine as a Sub-Specialty is in Stage 2 (Consultation Phase)
• New two-year medical training program• Routes of entry are IM, Neuro, Anesth for
Adults stream and Peds• Uncertain what the current one-year program
will evolve in to as per CFPC
DPC: WHERE ARE WE GOING?
• If/when a Sub-Specialty is formally created, the route of “practice eligibility” will likely be made available to physicians who have both completed the current one-year program and entered from a RCPSC specialty as well as current RCPSC members who maintain a clinical practice focused in Palliative Medicine
• Discussions at the CFPC are currently underway to determine if a certification and/or designation process will be instituted for the one-year program
DPC: WHERE ARE WE GOING?
• Based on what is determined, a practice eligible route is likely to be made available to current CFPC members who maintain a clinical practice focused in Palliative Medicine (with or without having completed the one-year training program)
• Family physicians who do not hold certification can acquire certification until December 31, 2012 via “Alternate Route to Certification” - see cfpc.ca
DPC: WHERE ARE WE GOING?
EOL CareHospice & Palliative Care
Curative / Remissive Therapy
Presentation Death
CG Support &Bereavement
Model of Collaborative or Shared Care
DPC: WHERE ARE WE GOING?
EOL CareHospice & Palliative Care
Curative / Remissive Therapy
Presentation Death
CG Support &Bereavement
Model of Collaborative or Shared Care Its time to move beyond this
DPC: WHERE ARE WE GOING?
Complex palliative care-related needs
Basic palliative care-related needsPt A
Pt C
Pt B
Pt D
Pt E
Illness trajectory EOL
Most will have needs requiring only basic PC skills (Pt A)
Others will occasionally require specialty level PC (Pts B, D)
A small number with highly complex needs will indefinitely require specialty level PC (Pts C, E)
LEVELS OF PALLIATIVE CARE
PROVISION OF PALLIATIVE CARE
Academic Mandate
Patient Volumes
Description of Patient
Needs
Levels of Care Expertise
Description of Provider Role
Care Setting
• Complex needs unresponsive to basic care or established protocols;• Require highly individualized care plans
• Experts in PC; consults to secondary and primary level providers; Leaders in PC research & education
• All care settings require at least access to tertiary level expertise generally hospital based
• PC needs exceed those available from primary care;• Pt/families ability to cope is compromised
• Extensive PC knowledge in PC; model of care may be consult only to direct care; most often share care with primary team
• Required in all care settings (home, acute care, LTC, CCC ambulatory clinics)
• Largest group of patients;• Most needs met through primary care providers (i.e. non-PC specialists
• Basic or primary level PC related clinical skills (pain and Sx Mx; basic psycho-social care)
• All care settings
Tertiary Level
Secondary Level
PC Expertise
Primary LevelPC Expertise
Academic Mandate
Patient Volumes
Description of Patient
Needs
Levels of Care Expertise
Description of Provider Role
Care Setting
• Complex needs unresponsive to basic care or established protocols;• Require highly individualized care plans
• Experts in PC; consults to secondary and primary level providers; Leaders in PC research & education
• All care settings require at least access to tertiary level expertise generally hospital based
• PC needs exceed those available from primary care;• Pt/families ability to cope is compromised
• Extensive PC knowledge in PC; model of care may be consult only to direct care; most often share care with primary team
• Required in all care settings (home, acute care, LTC, CCC ambulatory clinics)
• Largest group of patients;• Most needs met through primary care providers (i.e. non-PC specialists
• Basic or primary level PC related clinical skills (pain and Sx Mx; basic psycho-social care)
• All care settings
Tertiary Level
Secondary Level
PC Expertise
Primary LevelPC Expertise
PROVISION OF PALLIATIVE CARE
WHERE ARE WE GOING AND HOW WILL WE GET THERE?
OUR initial strategy will be to BUILD CAPACITY
DIVISION OF PALLIATIVE CARE
DPC: HOW WILL WE GET THERE?
It should not be advocacy for
earlier integration of the PC field in the illness trajectory…
It should be advocacy for earlier
integration of both PC philosophy and PC-related clinical skills
DPC: HOW WILL WE GET THERE?
If oncology has just recently integrated palliative care-related clinical skills in to their training programs, what about every other illness known to be incurable and the IP teams who care for
them?
…CHF, COPD, Dementia, ND, CKD, cirrhosis, metabolic disorders…
DPC: HOW WILL WE GET THERE?
1996-97
1997-98
1998-99
1999-00
2000-01
2001-02
2002-03
2003-04
2004-05
2005-06
2006-07
2007-08
2009/2010
2010/2011
2011/2012
2012/2013
2013/2014
2014/2015
2015/2016
2016/2017
2017/2018
2018/2019
2019/2020
2020/2021
2021/2022
2022/2023
2023/2024
2024/2025
2025/2026
2026/2027
2027/2028
2028/2029
2029/2030
2030/2031
2031/2032
2032/2033
2033/2034
2034/2035
2035/2036
0
20
40
60
80
100
120
140
160
80 80 80 81 81 81 83 84 85 84 8689
92 94 96 98 100102104106108110112114116118120122124127129131134137
140143
145148
152
Num
ber
of D
eath
s (1
000'
s)
Total Number of Deaths projected to increase: By 20% in 10 years from 2010-11 to 2020-21. By 65% in 25 years from 2010-11 to 2035-36.
Actual and Projected Deaths in Ontario: 1996-2036
WE ARE HERE!!!
HOW WILL WE BUILD CAPACITY?
INTEGRATION EDUCATION
COMMUNITY BUILDING
DPC: HOW WILL WE GET THERE?
DPC: INTEGRATION
BEGIN WITH DFCM• DPC Head: Site Visits • Faculty Appointments: Collaborative
Model with Site Chiefs• “DPC: A Resource for DFCM Faculty”
Next four slides outlines possible elements
• “DFCM Site Integration Tool Kit”
DPC: INTEGRATION
DFCM Site Integration Tool Kit • Examples of possible standard presentations
• “The DPC As A Resource to the DFCM: How to Have a Discussion with the DFCM Chief”
• “Strategies for Teaching Your Family Medicine Colleagues”
• “The Palliative Care You’re Providing But May Not Know It: Building Capacity Among Family MDs”
• As well, presentations on topics from brochure
DPC: EDUCATION
Repository of resources:• Resources for community building through
collaborations and sharing• Resources for Learners• Resources for Teachers
undergrad, postgrad, IPE, CE, other prof• Resources for Researchers• Resources for Leaders• Patient and Family Education Resources
DPC: COMMUNITY BUILDING
• DPC Face to Face Event - Sept/Oct 2012 • DPC New Member Orientation • DPC FAQs (What, Who, Where, Why, How)• Value-add vehicle supporting collaboration
DPC: WHAT CAN EACH OF US DO?
THIS IS A CALL TO ACTION
Each of us MUST consider ourselves an essential resource
Every professional interaction MUST have two components:
CLINICAL AND EDUCATIONAL
For EVERY professional interaction:• Contribute thoughtfully• Be willing to teach• Be precise & vigilant with your
words
DPC: WHAT CAN EACH OF US DO?
Each of us MUST view ourselves as leaders, ambassadors & educators as well as be thoughtful in:• How we contribute eg. discussions re: “Care
delivery models” • How we view consultations and referrals as
more than JUST patient/family care but as opportunities to educate our colleagues
“What can I teach, to whom, how and will my response differ next time?”
DPC: WHAT CAN EACH OF US DO?
With vigilance and respect, seek clarification, correct inaccuracies & teach colleagues, learners, family members, friends…
• “What do you mean by‘terminal’?”• “What do you mean by‘palliative’?”
“Oh you mean her illness is incurable.”
“What’s her performance status and level of function as well as goals for her care?”
DPC: PRECISION WITH OUR WORDS
With vigilance and respect, seek clarification, correct inaccuracies & teach colleagues, learners, family members, friends…
“Jeff, can I talk to you about a referral we have made to pain clinic?”
“Nope. But happy to speak about a referral made to palliative care clinic. Did you tell the pt she was being seen in palliative care clinic?”
DPC: PRECISION WITH OUR WORDS
DPC: OUR TIME IS NOW!!!
Who are we?
What does being a DPC Member mean?
What do we do?
Why do we matter?
Where are we going?
How will we get there?
What can each of us do?