What Unites Palliative Care on Both Sides of the Atlantic? Experiences of a Third-Year Medical Student

Abstract

Dear Editor:

This is a comparison of a third-year medical student's rotations with palliative care (PC) consult teams at two different academic hospitals: one week at Mount Sinai Hospital (MSH) and four weeks at La Clínica Universidad de Navarra (CUN). I compare the two institutions and how they assess and treat pain (physical, psychosocial, and spiritual) and other problems (intangibles). PC team and hospital characteristics are summarized in Table 1.

Table 1.

Palliative Care Team and Hospital Characteristics ^a

	MSH	CUN
Total hospital beds	1171	300
Total number of physicians	2510	470
New inpatient PC consults (per month)	190	15^b
Number of teams	2 primary teams +1 specialty team + PC unit team	2 primary teams
Composition of primary team	- 1 attending	- 1 attending
	- 1–2 geriatrics/PC fellows	- 1 nurse
	- 1 nurse practitioner	- 1 oncology fellow and 1 psychologist shared
	- 1 social worker and 1 chaplain shared	- Chaplains and social workers shared throughout the hospital
Types of consults	- Established for a long time	- Grew out of the oncology service due to historical reasons
	- Services are integrated across the hospital ranging from cancer to heart disease	- Receives consults almost entirely of stage IV cancer patients from the OT^c

Information obtained from experience and asking members of the PC team at each respective institution.

CUN teams see both inpatient and outpatient (located on the same floor) and receive about 50 new outpatient consults per month.

Frequent formal and informal meetings between OT and PC team

CUN, La Clínica Universidad de Navarra; MSH, Mount Sinai Hospital; OT, oncology team; PC, palliative care.

Physical

In the initial assessment of all patients, CUN's nurse gathers information through the Edmonton Symptom Assessment System-revised.¹ Management of physical pain differed slightly between teams depending on medications available and attending and institutional preferences. Furthermore, CUN focused on magnesium levels playing a role in neuropathic pain,² and MSH more frequently used patient-controlled analgesia (PCA) for pain control.

Psychosocial

CUN's psychologist used Dignity Therapy³ as its main mode of counseling; MSH used services ranging from massage therapy to counseling by social workers. Official family meetings were much more frequent at MSH, although there were many informal family meetings at CUN. MSH prioritized patients' rights to be involved in all aspects of care, and would conduct all family meetings with the patient unless the patient refused or was incapable of making a decision. CUN would frequently speak with caretakers separately outside of the room, which helped in gauging level of understanding, gaining trust, obtaining extra information, and building a sense of teamwork in caring for the patient. Both teams frequently used medications to treat depression, delirium, and anxiety.

Spiritual

The MSH PC chaplain was present at morning rounds and family meetings and would come to the patient or the family separately based on family meeting discussions. The CUN chaplains were not assigned to the PC team, but all departments had their own chaplains who would go from room to room, engaging all patients (and staff). The physicians at CUN frequently conducted additional spiritual counseling.

Intangibles

Both teams were attentive to the patient's environment. They ensured that the room was quiet, that the patient was at eye level, and that the appropriate persons were present. They used touch, listening, and moments of silence as means of nonverbal communication.

Discussions with the consulting team focused on information that the patient would want to know. Discussions with the patient focused on how the disease affected him or her and the family. Both teams were attuned to ensuring relief of the smallest of symptoms while accepting the limits of their abilities, especially as the patient neared the end of life. They would jump into action very quickly if they saw a patient was in pain, personally delivering morphine when the nurse was too busy (MSH) or finding a wheelchair for a patient who seemed too weak to walk to the consult room (CUN).

Both teams had a deep sense of awareness. They could sense when pain was more than physical, even if the patient could only express the physical, and maneuver through family dynamics. They paid attention to the small things, like changing the channel from a show to soothing music for a somnolent patient (MSH) or requesting a change in lunchtime based on cultural preference (CUN).

In conclusion, although there were small differences in modes of delivery of care, the underlying core values of PC, reflected in the “intangibles,” were the same in both institutions. Variation mostly stemmed from institutional and cultural differences.

References

Carvajal

, Hribernik

, Duarte

, et al.: The Spanish version of the Edmonton Symptom Assessment System-revised (ESAS-r): First psychometric analysis involving patients with advanced cancer. J Pain Symptom Manage, 2013; 45:129–136.

Centeno

, Lopez Saca

: An update on the importance of monitoring serum magnesium in advanced disease patients. Curr Opin Support Palliat Care, 2013; 7:396–405.

Johnston

, Lawton

, McCaw

, et al.: Living well with dementia: Enhancing dignity and quality of life, using a novel intervention, Dignity Therapy. Int J Older People Nurs, 2015. (E-pub ahead of print.)