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HMC Inpatient Palliative Care Consultation Service Orientation

Welcome to the Palliative Care Service at HMC (Harborview Medical Center). As part of HMC’s primary mission, we serve some of the most vulnerable and underserved communities in our area. Additionally, HMC is the only level 1 trauma center for WA, AK, ID, and MT and a leader in neurosurgery, neurology, orthopedics, vascular surgery and HIV/AIDS care. This breadth and wealth of experience will provide you with unique tools necessary to care for all patients facing serious illness. It will also afford you the opportunity to work with deeply committed staff who works hard to provide the best care possible to these individuals.

Palliative care is an interprofessional team approach that provides an extra layer of support to patients and their families facing serious illness. Our primary goal is improve quality of life and relieve stress by addressing physical, emotional, psychological, social, spiritual and cultural needs. This is accomplished by learning the patient’s story, exploring their goals and values, assisting with medical decision making, developing individualized care plans, providing pain and symptom relief, and offering spiritual, cultural and psychosocial support. The palliative care team works alongside the primary care team to provide these services. Palliative care is appropriate at any stage of illness, from the time of diagnosis through the end of life and bereavement. It can be provided in conjunction with curative and life prolonging treatments.

LOCATION, TEAM AND HOURS OF OPERATION

  • Location: 2WH sky bridge, Room 2WH 89 (step in; we use the computers to the left of the door).
  • Hours: 8:00am-6:00pm, Monday through Friday (attendings arrive between 8:15-8:30am), so please arrive at 8:30am on your first day NOTE: If your first day is Tuesday, go to the Palliative Care Conference @ 8:00am, Pat Steel Building, room 2097.
  • Team: Our team consists of Tonda Anderson PA-C (team leader), a physician (rotates ~1-2 weeks), Karen Clay LICSW, Laura Newcomb RN Manager, Kaity Pak ARNP and often a representative from spiritual care. You will work with all members of our team throughout your rotation and your notes will be co-signed by the MD, PA-C or ARNP. The MD works Monday -Sunday and covers the overnight and weekend call.

CORES

Most services at HMC use CORES to keep track their daily patient list. When selecting your CORES list: choose HMC→PalliativeCare→Team 1→Active→Go to Patient List. Patients will be added to CORES by whoever takes down the new consult and a brief description with the ID/HPI and surrogate contact information should be placed in the “Comments/Tasks” section; updates should be made by the team member who is primarily assigned to the patient. Please also put the patient’s main diagnosis in the “My Service Main Issue” section. NEVER delete a patient from the list. This is ONLY done by the PA-C/MD/ARNP on our team to assure appropriate follow up is arranged and to track QI data (total patients on the list are electronically captured at midnight so we try not to remove them until the day after discharge/death/signoff).

NEW CONSULTS

We get on average 2-6 new consults per day and carry a total of ~10-25 patients. For now, all new consults must have the approval of the attending provider from the primary team. If a new consult comes from someone other than the primary team (i.e. family, nursing etc.), first discuss the patient with your attending, and then call the primary service for that patient and ask permission to initiate a new consult. The only exceptions to this rule are the Trauma Nurse Coordinators since they always call at the request of the attending. We see the teams as our clientele and all efforts should be made to be courteous, professional and helpful. New consults are RARELY refused and attempts should be made to see the patient and/or family within 48 hours.

Our service is somewhat different than other rotations in that all initial consults should be done with a supervising provider (MD/PA-C/ARNP) and most follow ups should also be supervised. If you want to see a follow up patient on your own, discuss with your supervising provider first.You do NOT need to pre-round on your patients, only review their charts for overnight events. We think your experience is enriched by seeing various styles modeled and thus you will work with all members of our interprofessional team. Each patient is generally assigned one supervising provider and you will follow that patient with that provider with the MD as backup when needed. The first week of your rotation will be spent mainly observing and participating in follow up visits, however by the second week, we expect that you will begin to lead initial and follow up visits with the supervising provider there for feedback and support.

The palliative care consult pager will be carried by the fellow to accept and triage all new consults. If there is no fellow, or they are unavailable, this responsibility will fall either to the senior resident or the MD attending. When a new consult is requested please ask the following questions:

  1. Who is the primary attending for the service requesting the consult?
  2. What is the primary question(s) they want answered?
  3. Does the patient currently have decisional capacity? If not, why?
  4. Who are the key family members/friends/surrogate decision makers?
  5. Would the primary team like to be present for our visit?
  6. Does the patient have a PCP/outpatient specialists (nephrologist, oncologist etc.) and have they been updated or invited to participate in discussions?

Please let teams know that we prefer to meet patients and/or family before any large family meetings to allow us enough time to conduct a thorough consult and build rapport. Additionally, we try not to schedule initial consults past 4pm to allow enough time to finish the consult by 5pm and then complete notes before 6pm. However, when the service is very busy, this is not always possible.

TEMPLATES AND DOCUMENTATION

All initial consults and follow up visits should be documented using our team template. This template was created to assure accurate billing, encompass core principles of palliative care recommendations using the 8 domains of palliative care ( and to collect important QI data. There are three templates which are described below. We ask that all initial consults and follow up visits always include the patient’s surrogate decision maker information. These templates (initial consult and follow up) are available on the residency website, under HMC Palliative Care:

  1. Initial Consult Note: This note is intended to be for your first full assessment. All domains of palliative care in the recommendations sections should be addressed in some way.
  2. Follow Up Note: This note is for all follow up visits that are billable, address domains that are relevant, delete extraneous components, and always include the surrogate information.
  3. Brief Note: This note template is intended for short visits that are not billable. Some examples include if you stop by to meet a patient briefly and set up a meeting for a different day, or you had a short visit for social support. This note template is also used for medical information or communication with other providers when the patient and/or family is not seen, for example if you talked with the patient’s PCP on the phone and left a brief note about your conversation. Lastly, this template can be used for sign off documentation when the patient and/or family is not seen (please do not sign off on pts until discussed w/team).

OBSERVATION AND FEEDBACK

Communication is best learned through deliberate practice and this rotation provides unique opportunities for direct observation and feedback from supervising providers and your fellow trainees. All feedback should be timely, constructive and focused on key behaviors and skills. In general, if you are leading a visit, your supervising provider will do the following:

  1. Set a Learning Goal: Before the encounter, they will help you identify the learning opportunity, outline a specific learning goal, and help frame the skill challenge associated with that goal (for example, identifying and responding to emotion).
  2. Observe: Using active observation and real-time tracking they will collect data on the encounter. All trainees who are not leading the encounter will also write down their observations of the encounter. The supervising provider will also be there to guide the conversation when you are stuck.
  3. Debrief: After the encounter, the group will briefly review the visit, focusing on the learning goal you identified and ask the following questions:
  1. What did you do well?
  2. Anything you would do differently next time?
  3. What is one thing you learned from this encounter that you want to use again?
  4. What do you want to work on during the next encounter?

PRIMARY CARE PROVIDERS and OUTPATIENT SPECIALISTS

We are trying to make a concerted effort to involve the patient’s primary care provider, and/or primary outpatient specialists in the process. When a new consult is requested, please identify the PCP and contact them to ask if they want to be involved in any family meetings and if they have any additional insight into the patient’s situation. Ask what is the best way is to update them on any changes to the plan of care and disposition. Many PCPs and outpatient specialists have cared for these patients for a long time and are very close to their patients. This is particularly true of the following clinics; Primary Palliative and Supportive Care Clinic, International Clinic, Madison Clinic, Adult Medicine Clinic, Oncology and Nephrology among others. If a patient will be discharged home on hospice, ask them if they want to be their hospice provider. Please copy all relevant inpatient and outpatient providers involved in the patient’s care on your initial consult note and any further notes that contain important changes to the plan of care.

HMC CULTURE AND TEAMS

Since we work with a wide variety of teams, there are inherently different ways in which each operates and different ways through which we can be most helpful. Here are some tips when working with specific services:

1)Some services (examples include orthopedic surgery and neurosurgery) are extremely busy and may not have time or availability to implement recommendations. When making recommendations to these services, please offer to write any necessary orders in the patient’s chart if this would be helpful.

2)Some services (including neurology, medicine, and the trauma ICU), often want at least one member of their team to be present for the initial consult. Always invite a member of the primary service to be present for your evaluation. This can be helpful if prognostic or medical questions arise and helps improve communication. It is also an opportunity for others to learn primary palliative care skills. Whenever possible, please include the patient’s bedside RN and floor MSW in the conversation; this is especially important for any ICU patients.

  1. When setting up family meetings with the trauma ICU (TICU 1 or 2) that require their presence and/or otherwise include medical updates, contact the TICU fellow for that team or the Trauma RN Coordinator for that team.

3)Lastly, when the acute pain service has been consulted, they will be primarily responsible for any pain management changes or recommendations. This avoids confusion and duplicity. We often work closely with the pain service, especially for complex cases, and if you have a concern about how pain is being treated under these circumstances, discuss this with your attending.

REFERRALS TO THE PRIMARY PALLIATIVE AND SUPPORTIVE CARE CLINIC

We are very lucky to have an outpatient palliative care clinic at HMC called the Primary Palliative and Supportive Care Clinic. Patients who may benefit from their services include any patient with a serious illness and no PCP, patients who have a PCP, but the PCP requests help managing a complex symptom or delineating goals of care, patients with a PCP, but will be homebound or on hospice and their PCP cannot do home visits, or patients going to a SNF who would benefit from ongoing consultation. Note, we generally only act as consultants for patients going to SNFs and we do not go to all SNFs. If you have a patient you want to refer, try to identify them early in the process so that all necessary steps can be taken and allow time for the clinic to arrange an initial appointment. To make a referral for these services proceed with the following:

  1. Discuss the patient with your supervising provider.
  2. Call our Patient Care Coordinator Shinetra Pryor at 206-744-1450 to see if the patient is eligible.
  3. If the patient has a PCP, ask their permission prior to placing the referral.
  4. If the patient has a primary outpatient specialist (nephrologist, oncologist etc.), also ask their permission to place the referral.
  5. If permission is granted notify Laura Newcomb, our RN manager, who will coordinate the follow up with Shinetra Pryor and tell them whether the patient needs to be seen in their home or can come to clinic and the urgency for the initial outpatient visit (i.e. does the patient need to be seen within a week, or will 3-4 weeks be sufficient).
  6. Once confirmed, clearly document this plan in the patient’s chart under “disposition” in the assessment and plan with instructions to the primary team to refer the patient to the Primary Palliative and Supportive Care Clinic at time of discharge. Include the phone number in your note for Shinetra Pryor, 206-744-1450, if they have any scheduling questions and ask they cc Shinetra on the discharge summary.
  7. Cc any PCP, outpatient specialists, Laura Newcomb and Shinetra Pryor on your note in ORCA.
  8. Notify the inpatient MSW and the primary team of the plan.

SUPPORT SERVICES, INTERPRETERS, CULTURAL MEDIATORS

In addition to our team, we utilize many other support services including spiritual care, rehabilitation psychology, recreational therapy, and canine assisted therapy. These services are either listed in the middle section of our contact list at the end of CORES, or can be contacted through the paging operator. Some services will require a consult to be placed by the primary team. There are a few attendings on our team who are trained in Reiki healing and are available to patients as their schedule permits.

HMC has excellent interpreter services and in addition to standard interpretation, there are some individuals trained in cultural mediation (including, but not limited to Spanish, Somali, Vietnamese and Cambodian). Cultural mediators help us translate not only the language but also help navigate sensitive cultural concerns, especially around illness and death. Many of them also act as caseworkers in the community and are well known and trusted by our patients. If an interpreter is needed, whenever possible we use in person cultural mediators for family meetings or initial consults. Many of them coordinate their own schedules and their information is listed in the middle column of the CORES contact list. If they are unavailable, then an in person interpreter should be requested, and if they are unavailable, then phone interpretation can be used.

DAILY SCHEDULE, TEACHING ROUNDS AND CONFERENCES

While on this rotation, attendance at your normally scheduled conferences should be a top priority. If your attending does not remind you to attend conference, please remind them you will need to leave at the designated time. If an important family meeting or learning opportunity is happening at the same time, you can decide which you think will be the most valuable experience. Below is a sample weekly schedule (though days can vary depending on the demands of the service and attending preferences).

Work rounds:

-To ensure effective and efficient rounds, please provide one-liners on your patients including your plan of care for that day

-Please remember to sign into CORES each morning and sign out to the attending at the end of the day.

-Before signing out of CORES, please remember to update CORES as needed.

HMC Palliative Care Consult Service Weekly Schedule
Monday / Tuesday / Wednesday / Thursday / Friday
8-9: Read charts
9-10: Team Rounds
4-5:30pm (Fellows Only, Mandatory) VA Professional Development Series
(Usually 2nd Monday Q Month) / 8-10:PalliativeMedicine Conferences
(PSB 2097, All, Mandatory)
10:30-11: Team Rounds
10-11am:(Fellows Only, Mandatory) Gruenewald’s Symptom Management Cases
(PSB 2097 (2nd Tuesday Q Month)
11:15-12: Fellows Meeting (Fellows Only, Mandatory)
(PSB, Geri Library)
(2nd Tuesday Q Month)
10:30-11:30: (Fellows Only, Mandatory) Pre-Clinic Conference
(4th Tuesday Q Month)
12:30-6: (Fellows Only, Mandatory) HMC Home Panel Visits
(2nd and 4th Tuesday Q Month)
Note: Fellows are expected to check in with the HMC clinic staff after morning teaching/meetings on a weekly basis. / 8-8:30: Read charts
8:30-9: Teaching Session
9-9:30: Card flip rounds
12:30-6: (Fellows Only, Mandatory) Bricks and Mortar PC Clinic (1st, 3rdand 5thWeek Q Month)
12-1:Ethics Conference (R/T)
(2nd Wednesday Q Month)
12:30-1: Frye Art Museum Mindfulness Meditation
(Wednesday Q Week) / 8-9: Read charts
9-10: IDT Rounds / 8-8:30: Read charts
8:30-9: Teaching Session
9-9:30: Card flip rounds
9:30-10am:
Team reflection
12-12:30: Laughter Yoga, Patient Resource Center, Ground Floor
(Fridays Q Week)

Other Conferences: