I have begun to a collect a list of interventions that might be
accomplished through the initial work of one individual, although it is not
comprehensive. Some interventions are clearly of larger scale than others, some
requiring the cooperation of a number of individuals. Some require only a
single committed person. Some examples have already been undertaken by
individuals and groups, and some are at this point only ideas, as far as I
know. The key point is that just as there is always something you can do to
help an individual patient, so, too, there is always something that can be done
to improve the system of care. My hope is that this list will stimulate readers
to try something out, whether it is on this list or not, and to share their
actions with others.
- Develop talks,
handouts, and laminated cards.
- Share your work with
others. For example, you might submit your curricula
to the End of Life Physicians Educational Resource Center at http://www.
eperc.mcw.edu. Submitted educational material will be peer reviewed and listed
on their Web site, allowing you to make this material available to others.
- Obtain a dedicated slot
in your organization's conference schedule for topics related to palliative
- Evaluate the
educational content offered in your facility for the percentage and quality of
palliative care content.
- Sample the available
textbooks in the library, the chief resident's office, and clinic offices. How
many of these have quality palliative care content? If there is no other way to
get it, buy a good textbook on
palliative care and donate it, conspicuously, to an area actually used by
- Feed back collected
information to important change agents - clinic chiefs, residency program
directors, department chairs, and so on - with kudos for those doing good work
and suggestions for areas that might need attention.
- Model conducting
literature searches for questions related to palliative care on the computer in
the resident call room. Bring in palliative care articles to the ward team
regarding symptom management that result from your search.
- Add major palliative
care websites to favorite/bookmark lists for
computers with internet access, such as Growth House at
http://www.growthhouse.org - the major connection
point for virtually everything relating to palliative care on the net.
- When hearing
presentations on research with possible implications for palliative care, ask
specific questions: How were quality-of-life issues addressed in the study? How
do researchers think this new finding might result in less suffering?
- Do a small study or
review of a palliative care issue. Present this at a conference or submit it
- Work to incorporate palliative
care issues into existing educational forums. Examples are residents reports,
ICU rounds, morbidity and mortality conference, clinic teaching sessions, and
- Review your hospital
formulary's commonly used palliative medications. Advocate for those
medications that have a special niche in palliative care.
- Assess how symptom
assessment and management is included or not included in notes and care plans
by physicians, nurses, and other clinicians.
- Target a specific
intervention, such as using subcutaneous rather than IM shots of morphine,
increasing the use of long-acting opioids for chronic
pain, and the barriers to proper opioid use caused by
local policies that actively discourage use, such as frequent renewal policies.
- Address common
practices based on little, if any, data that may be harmful, such as chronic
use of meperidine and the use of lorazepam
as a sole agent for nausea.
Decision Making and Communication
- Take a stand on
assessment and documentation of patient preferences. Set standards for yourself
and those you supervise. If you are an attending or resident physician, what do
you expect to see on the history and physical charts regarding patient
preferences? What do you say to your subordinates? Is documentation of
preferences a good idea, an option, or an expectation? Do you model this? How
important is such documentation relative to other data you would expect to see,
such as an examination of the heart and lungs?
- Have specific skills
included on a sanctioned procedure check-sheet for residents. What skills might
be listed? Sharing bad news, pronouncing a patient, notifying family,
- Model these skills to
those you supervise.
- Make brochures and
documents, such as durable power of attorney and out of hospital DNR forms,
available in key areas, such as clinics.
- Do an assessment of the
resources available to support patients and families in your community, such as
disease-specific support groups and ethnic support groups.
- Identify useful websites that can help patients and families with special
needs and give them to patients during clinic visits.
- Learn about special
transportation systems, such as volunteer groups and special elderly
transportation systems, that get patients and families where they need to go.
- Identify bereavement
support in your community both for routine and complicated bereavement.
- Identify interpreters
and cultural guides for your population and learn how you can access them. Make
this available to others.
- Check for documentation
of psychological factors in hospital and clinic notes, such as documentation of
possible depression or delirium.
- Ask families of
patients (especially in ICUs and nursing homes) to bring in a photo of what the
patient looked like when well, and post it in a visible spot.
- Add a profile of who
the patient was during morbidity and mortality conferences - a photo, video,
statement, or poem to remind participants that the patient was more than pathologic
- Assess bereavement
support in your facility, especially in areas when high-impact deaths occur,
such as the ER, transplant units, and ICUs. Work with allies to establish a
policy that the families of all patients who die in your facility receive a
minimum of one bereavement follow-up call.
- Work with your billing
office to ensure that once a patient dies, a bill is not subsequently addressed
to the deceased.
- Rename your inpatient
waiting room a "family room," then stock it so a family would want to be there,
with toys, video tapes, books, and magazines that people might actually want to
read. Get staff or volunteers to donate kids' videos and used books to the
room. Make it a matter of ward staff pride to create the most homelike family room
in the facility.
- Obtain a portable CD or
tape player and ask staff to bring in old CDs and tapes that patients or
families might enjoy.
- Start a "video legacy"
program. Get a video camera and a tape recorder (for those patients who would
rather not be remembered looking ill). Offer to tape messages and other
communication that can be sent to family members who cannot visit the patient
and to leave a valued memory for the family.
- Buy a stack of
telephone calling cards that can be given to patients and families in need to
enable them to make important long-distance telephone calls.
- Abolish "visiting
- Develop a system to
accommodate families of dying patients who are keeping a vigil in the hospital.
Where can they sleep - roll-away cots? Can they order a tray of food to be
delivered to them?
- Identify resources for
spiritual assistance for your patient population.
- Place telephone numbers
and lists of clergy in easily accessible places.
- Find reference books
for patients and families who request help with spiritual support.
- For patients who cannot
see, obtain audiotapes of major religious texts that
they can listen to.
Venues of Care
- Invite members of
agencies with whom you work to come to teach you what they can offer.
- Identify key contact
people within agencies with whom you work. Invite them to talk with your group
about how you might better serve the patients you share.
- Set up listserve/email links between people at different venues to
- Give awards to those
allies who are just beginning to do something new. Special achievement awards
can be created for house staff, ward teams, your clinic nurses - anyone who has
made a special effort related to care. (It does not take much effort to print a
unique special award document on a computer.)
Making a Difference in a Moment
Anything you do that can be
experienced by more than the individual with whom you are working can make a
difference simply by modeling good behavior.
- Model treating a severe
symptom, such as pain, as a medical emergency.
- Model spending as much
time (or more) with a dying patient as with a patient who has a fascinating
- Model finding a chair
and sitting down when making rounds.
- Model listening.
- Speak up politely but
firmly when people say something such as, "He's just here for pain control."
"He's just an old guy dying." "She's a social admission." "He's just here for
- Make a statement
regarding your priorities to those you supervise and to your supervisors:
"Working to provide good care at the end of life is a priority for me." "I'm
trying to document carefully patient preferences for all seriously ill
patients." "There are more important
things than placement." "Trying to provide excellent symptom management is as
important to me as is getting the right diagnosis." "I keep trying to see the
person behind the patient behind the disease."
Most great acts of history began with the actions of one
individual. The challenge, it seems, is for the individual to engage those
around him or her, to strike a resonant chord and thereby find allies in a
common cause. Clinicians really want to be of help, and we all know in our
hearts that we have a vested interest in good care; at some point almost all of
us will require it for those we love and for ourselves. This is our strength.
If we can engage this common interest in better care for the seriously ill and
dying, one can become many.
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