The Buddy System: An Intervention to Reduce Distress and Compassion Fatigue and Promote Resilience on a Palliative Care Team During the COVID-19 Pandemic.

The SARS-CoV-2 pandemic (COVID-19) dramatically increased the number of stressors on healthcare workers, including palliative care practitioners. Restrictions and increased demands on time made it difficult for the UMass Memorial Health palliative care team to utilize preexisting wellness strategies. In response to team members' stress reactions, a buddy system intervention was conceived and implemented to restore a sense of connection and self-efficacy (Phase 1). Our objective with this quality improvement project was to assess the feasibility and effectiveness of the buddy system and evaluate staff attitudes toward this intervention. After four months, feedback from team members informed redesign to a more structured buddy system (Phase 2). A mixed-methods design of this project included a qualitative online survey along with quantitative data collection with the Professional Quality of Life Scale V (ProQOL V) and the Brief Resilience Scale (BRS) during Phase 1. Phase 2 was also evaluated quantitatively with ProQOL V and BRS. Semi-structured interviews were conducted at the end of this project to enhance qualitative data on staff attitudes and beliefs. Of the 12 study participants, 10 completed all phases of the study. Participants reported the buddy system was a useful, easy-to-implement intervention for mitigating personal distress and compassion fatigue (CF) by providing a strong sense of support and connection to team members.

Paving the way for universal medical student training in serious illness communication: the Massachusetts Medical Schools' Collaborative.

BACKGROUND: Patients with serious illness look to their clinicians for discussion and guidance on high-stakes treatment decisions, which are complex, emotional and value-laden. However, required training in serious illness communication is rare in U.S. medical schools, with efforts at curricular reform stymied by competing institutional demands, lack of resources and accreditation requirements. We describe an approach to building and scaling medical student training in serious illness communication through the creation of a statewide collaborative of medical schools. METHODS: The Massachusetts Medical Schools' Collaborative is a first-of-its-kind group that promotes longitudinal, developmentally-based curricula in serious illness communication for all students. Convened externally by the Massachusetts Coalition for Serious Illness Care, the collaborative includes faculty, staff, and students from four medical schools. RESULTS: The collaborative started with listening to member's perspectives and collectively developed core competencies in serious illness communication for implementation at each school. We share early lessons on the opportunities, challenges and sustainability of our statewide collective action to influence curricular reform, which can be replicated in other topic areas. CONCLUSIONS: Our next steps include curriculum mapping, student focus groups and faculty development to guide successful and enduring implementation of the competencies to impact undergraduate medical education in Massachusetts and beyond.

PPE Portraits-a Way to Humanize Personal Protective Equipment.

The use of personal protective equipment (PPE) has skyrocketed, as providers don masks, glasses, and gowns to protect their eyes, noses, and mouths from COVID-19. Yet these same facial features express human individuality, and are crucial to nonverbal communication. Isolated ICU patients may develop "post intensive-care syndrome," which mimics PTSD with sometimes debilitating consequences. While far from a complete solution, PPE Portraits (disposable portrait picture stickers - 4" × 5") have the potential to humanize care. Preparing for a larger effectiveness evaluation on patient and provider experience, we collected initial qualitative implementation insights during Spring 2020's chaotic surge preparation. Front-line providers reported more comfort with patient interactions while wearing PPE Portraits: "It makes it feel less like a disaster zone [for the patient]." A brief pilot showed signs of significant adoption: a participating physician requested PPE Portraits at their clinic, shift nurses had taken PPE Portraits with them to inpatient services, and masked medical assistant team-members requested PPE Portraits to wear over scrubs. We believe PPE Portraits may support patient care and health, and even potentially healthcare team function and provider wellness. While we await data on these effects, we hope hospitals can use our findings to speed their own implementation testing.

A Call to Action: Using Curriculum Mapping at Four Medical Schools in Massachusetts to Advance Serious Illness Communication Training in Undergraduate Medical Education.

Background: Practicing physicians require serious illness communication (SIC) skills to ensure high-quality, humanistic care for patients and families as they face life-changing medical decisions. However, a majority of U.S. medical schools do not require formal training in SIC and fail to provide students deliberate practice before graduation. The Massachusetts Medical Schools' Collaborative was created to ensure that students receive foundational SIC training in undergraduate medical education. This Collaborative developed a curriculum-mapping tool to assess SIC at four medical schools. Objective: We aimed to understand existing educational activities across four medical schools and identify opportunities to build longitudinal, developmentally based curricular threads in SIC. Design: From July 2019 to April 2021, faculty, staff, and medical students assessed current educational activities related to five core competencies in SIC, adapted for students from national competencies for palliative medicine fellows, using a curriculum mapping tool. Measurements: The group selected 23 keywords and collected metrics to describe the timing, instruction and assessment for each school's educational activities. Results: On average, there were only 40 hours of required curricula in SIC over four years. Over 80% of relevant SIC hours occurred as elective experiences, mostly during the postclerkship phase, with limited capacity in these elective experiences. Only one school had SIC educational activities during the clerkship phase when students are developing clinical competencies. Assessment methods focused on student participation, and no school-assessed clinical performance in the clerkship or postclerkship phase. Conclusions: Medical schools are failing to consistently train and ensure basic competency in effective, compassionate SIC. Curriculum mapping allows schools to evaluate their current state on a particular topic such as SIC, ensure proper assessment, and evaluate curricular changes over time. Through the deliberate inclusion of SIC competencies in longitudinal curriculum design, we can fill this training gap and create best practices in undergraduate medical education.

Curricular Reform in Serious Illness Communication and Palliative Care: Using Medical Students' Voices to Guide Change.

PURPOSE: To gather and leverage the voices of students to drive creation of required, integrated palliative care curricula within undergraduate medical education in Massachusetts, which is lacking in a majority of U.S. medical schools. METHOD: The study was conducted by the Massachusetts Medical Schools' Collaborative, a working group committed to ensuring all medical students in Massachusetts receive foundational training in serious illness communication (SIC) and palliative care. Eight focus groups (2 per participating medical school) were conducted during January-May 2021 and included a total of 50 students from Boston University Chobanian & Avedisian School of Medicine, Harvard Medical School, Tufts University School of Medicine, and the UMass Chan Medical School. Data collected from focus groups were discussed and coded. Themes were identified using the immersion/crystallization qualitative data analysis approach. RESULTS: Six key themes emerged. Students viewed SIC as essential to high-quality medical practice regardless of specialty, and believed training in SIC skills and palliative care should be required in medical school curricula. Students preferred to learn and practice these skills using frameworks, particularly in real-world situations. Students recognized the expertise of palliative care specialists and described them as a scarce, often misunderstood resource in health care. Students reported it was mostly "luck" if they were included in family meetings and observed good role models. Finally, students desired practice in debriefing after difficult and emotional situations. CONCLUSIONS: This study confirms long-standing themes on students' experiences with SIC and palliative care topics, including feeling inadequately prepared to care for seriously ill patients as future physicians. Our study collected students' perspectives as actionable data to develop recommendations for curricular change. Collaborative faculty also created recommendations based on the focus group data for immediate and ongoing SIC and palliative care curricular change in Massachusetts, which can apply to medical schools nationwide.

Improving Access to Specialist Palliative Care for Patients With Catastrophic Strokes Using Best Practice Advisory- a Feasibility Study.

Background and Purpose: The American Heart Association and American Stroke Association (AHA/ASA) strongly recommend specialty palliative care (PC) for all patients hospitalized with life-threatening or life-altering strokes to provide expert symptom management, improve communication, promote shared decision-making and relieve suffering. We piloted an intervention to remind physicians about high PC needs of their patients admitted with catastrophic stroke. Methods: We worked with colleagues from medical informatics to create a "Best Practice Advisory" (BPA) to recommend a goals-of-care conversation and PC consultation for patients with a National Institutes of Health Stroke Scale (NIHSS) score of 20 or more in our electronic medical record (Epic). We evaluated the impact of this BPA, after implementation, on the number and timing of PC consults and reviewed barriers to this system change. Results: The BPA was operational in Jan 2019. Data analysis showed that it fired for all patients with an entered NIHSS score of ≥20. Though a large portion of the BPAs (more than 90%) were acknowledged without documented reason (after selecting "do not order"), PC consultations per 100 patients with triggered BPA increased from the first year of implementation (11.7 in 2019) to the next 2 years (20.7 in 2020, 15.6 in 2021). Also, the providers learned to manage BPA alerts better resulting in more than 30% reduction in the number of BPA alerts fired for each patient encounter in 2020-2021 compared to 2019.

Assessing Goals-of-Care Documentation during the COVID-19 Patient Surge in an Academic Safety-Net Medical Center.

Context/Objectives: It is paramount that clinicians assess and document patients' priorities to guide goal-concordant interventions, especially during a public health crisis. Design: Retrospective chart review. Setting: Academic safety-net medical center in central Massachusetts, United States. Methods: We examined electronic medical records (EMRs) to discern goals-of-care (GOC) conversations with COVID-19 patients seen at some point by palliative care during their hospitalization, and all clinicians' use of a structured note template during the peak incidence of COVID-19 from March to May 2020. Patients were grouped based on comorbidities and preadmission living situation. GOC discussions were categorized into three types: code status decisions, other treatment decisions, and no treatment decisions. Results: Nearly all (97%) patients had GOC documentation within 48 hours of admission. Forty-four percent of first GOC conversations incorporated the template. Patients with dementia living in nursing facilities had GOC documentation within hours of hospital admission, whereas healthier patients had their first GOC conversation at one week of hospitalization. Decisions about code status predominated in the first (83%) and second (49%) discussions, followed by a focus on other treatment decisions in subsequent discussions (44%-57%). Many did not require a treatment decision (19%-27%) but focused on quality-of-life definitions. Nearly all survivors were discharged to a facility and only four patients returned home. Many survivors died within three months (case fatality rate: 77%). Conclusions: GOC documentation using a structured template combined with easy EMR retrievability and clinician training holds promise for aligning patients' values with real-time medical decisions, during and after the pandemic.

Use of Palliative Care Music Therapy in a Hospital Setting during COVID-19.

As many hospitals scaled back integrative therapies during the COVID-19 pandemic, we instead turned to the multifaceted qualities of music to bridge physical and social divides. In this report, we describe palliative care music therapists as frontline providers utilizing evidence-based approaches to support healing and recovery for patients in the intensive care unit, patient and family care at end of life, and staff wellness. We provide examples of music therapy (MT) to promote successful weaning from mechanical ventilation, create bedside rituals and legacy gifts for dying patients and their families, and provide real-time support for overwhelmed staff. Despite barriers brought on by the pandemic, the sensory and emotional immediacy of music bridged social distances at critical moments and addressed "suffering beyond words" among patients, families and health care workers. Our experience reinforced the need for MT as standard of interdisciplinary care during the pandemic and beyond.

Effective Goals-of-Care Conversations: From Skills Training to Bedside.

Introduction: Goals-of-care (GOC) conversations are essential to ensure high-quality care for people with serious illness. We developed a simulation experience to train internal medicine residents in GOC conversations near end of life, followed by a real-life GOC conversation as a Mini-Clinical Evaluation Exercise (Mini-CEX) including direct feedback from participating patients. Methods: The 3-hour simulation session trained teams of two learners each to interact with standardized patients portraying a patient with end-stage heart failure and an accompanying family member. Residents completed pre- and postsurveys regarding their self-assessed abilities and confidence in conducting these conversations. Piloted in 2016, the Mini-CEX was completed in 2017 with 28 residents 3-9 months after simulation. Patients and participating family members were invited to complete an optional, deidentified survey of their experience. Results: From 2015 to 2017, 84 residents completed simulation training. Ninety percent of postsurvey responders felt more prepared to conduct GOC conversations after simulation compared to 42% before training. Eighty percent or more reported confidence in discussing GOC (previously 67%), prognosis (previously 62%), and hospice (previously 49%). Analysis of Mini-CEX scores revealed that the majority of residents' skills were the same or improved compared with their performance in simulation; more than 70% demonstrated improvement in ensuring patients' comfort, displaying empathy, and recognizing/responding to emotion. Almost all patients and families reported feeling heard and satisfied with their conversation with the resident. Discussion: This curriculum was well received, and initial data support its effectiveness in enhancing residents' self-perceived confidence and interpersonal skills in real-world patient encounters.

Provider Perceptions of a Humanizing Intervention for Health Care Workers-A Survey Study of PPE Portraits.

CONTEXT: Reports from patients and health care workers dealing with coronavirus disease 2019 (COVID-19) underscore experiences of isolation and fear. Some of this experience results from the distancing effect of masks, gloves, and gowns known as personal protective equipment (PPE). One approach to bridging the divide created by PPE is the use of PPE portraits, postcard-sized pictures affixed to PPE. OBJECTIVES: Our confidential electronic mail-based survey aimed to quantify provider attitudes toward PPE portraits. METHODS: PPE portraits were piloted at an academic safety-net health system experiencing a COVID-19 patient surge during April-May 2020, necessitating use of full PPE for COVID-positive patients and surgical masks in all hospital settings. Our survey assessed staff exposure to PPE portraits, attitudes toward PPE portraits, and potential program expansion. For staff wearing PPE portraits, we also assessed perceptions of interactions with other staff and patients/families and impact on personal well-being. The University of Massachusetts Medical School's Institutional Review Board designated this as a quality improvement project (#H00020279). RESULTS: More than half of survey respondents (n = 111 of 173; 64%) reported exposure to PPE portraits. Attitudes toward PPE portraits were positive overall, with agreement that PPE portraits were a good idea (89%), improved provider mood (79%), enhanced perception of team connection (72%), and more positive among those who reported exposure. Open-ended responses (n = 41) reinforced positive survey data and also raised concerns about infection control (n = 6), cost/logistics (n = 5), and provider vulnerability (n = 3). CONCLUSION: Providers report that PPE portraits may represent a positive patient-centered idea that helps reassure patients, is well received by interdisciplinary staff, and may enhance patient and team interactions. Potential adaptations to address concerns include photo pins and donor/patient and family experience department support for costs.

Health System Advance Care Planning Culture Change for High-Risk Patients: The Promise and Challenges of Engaging Providers, Patients, and Families in Systematic Advance Care Planning.

BACKGROUND: The success of a facilitator-based model for advance care planning (ACP) in LaCrosse, Wisconsin, has inspired health systems to aim for widespread documentation of advance directives, but limited resources impair efforts to replicate this model. One promising strategy is the development of interactive, Internet-based tools that might increase access to individualized ACP at minimal cost. However, widespread adoption and implementation of Internet-based ACP efforts has yet to be described. OBJECTIVE: We describe our early experiences in building a systematic, population-based ACP initiative focused on health system-wide deployment of an Internet-based tool as an adjunct to a facilitator-based model. METHODS: With the sponsorship of our healthcare system's population health leadership, we engaged a diverse group of clinical stakeholders as champions to design an Internet-based ACP tool and facilitate local practice change. We describe how we simultaneously began to train clinicians in ACP conversations, engage patients and health system employees in thinking about ACP, redesign clinic workflows to accommodate ACP discussions, and integrate the Internet-based tool into the electronic medical record (EMR). RESULTS: Over 18 months, our project engaged two subspecialty clinics in a systematic ACP process and began work with a large primary care practice with a large Medicare Accountable Care Organization at-risk population. Overall, 807 people registered at the Internet site and 85% completed ACPs. CONCLUSION: We learned that changing culture and systems to promote ACP requires a comprehensive vision with simultaneous, interconnected strategies targeting patient education, clinician training, EMR documentation, and community awareness.

Temperature can interact with landscape factors to affect songbird productivity.

Increased temperatures and more extreme weather patterns associated with global climate change can interact with other factors that regulate animal populations, but many climate change studies do not incorporate other threats to wildlife in their analyses. We used 20 years of nest-monitoring data from study sites across a gradient of habitat fragmentation in Missouri, USA, to investigate the relative influence of weather variables (temperature and precipitation) and landscape factors (forest cover and edge density) on the number of young produced per nest attempt (i.e., productivity) for three species of songbirds. We detected a strong forest cover × temperature interaction for the Acadian Flycatcher (Empidonax virescens) on productivity. Greater forest cover resulted in greater productivity because of reduced brood parasitism and increased nest survival, whereas greater temperatures reduced productivity in highly forested landscapes because of increased nest predation but had no effect in less forested landscapes. The Indigo Bunting (Passerina cyanea) exhibited a similar pattern, albeit with a marginal forest cover × temperature interaction. By contrast, productivity of the Northern Cardinal (Cardinalis cardinalis) was not influenced by landscape effects or temperature. Our results highlight a potential difficulty of managing wildlife in response to global change such as habitat fragmentation and climate warming, as the habitat associated with the greatest productivity for flycatchers was also that most negatively influenced by high temperatures. The influence of high temperatures on nest predation (and therefore, nest predators) underscores the need to acknowledge the potential complexity of species' responses to climate change by incorporating a more thorough consideration of community ecology in the development of models of climate impacts on wildlife.