A Pilot Cross-Discipline Evidence-Based Palliative Care Curriculum for Postgraduate Medical Trainees.

INTRODUCTION: It is widely recognized that physicians of all backgrounds benefit from having a general palliative care skill set to optimally manage their patients at the end of life. However, strategies to teach palliative care skills to trainees outside palliative medicine vary widely. In this report, we provide an evidence-based and cross-disciplinary palliative care framework applicable to a spectrum of specialty training environments and intended for nonpalliative care trainees. INNOVATION: We developed and implemented a concise, multimodal, and evidence-based pilot palliative care curriculum focused on essential general palliative care skills required by physicians providing patient care along the continuum of life across specializations. A needs assessment (local research, literature review, and consensus expert opinion) in combination with learner characteristics (Kolb Learning Style Inventory, Palliative Medicine Comfort and Confidence Survey, and knowledge pretest) informed the development of a curricular outline. The first iteration of the curriculum was formulated and delivered. Extensive evaluation, reassessment, and feedback led to a second iteration, which is presented here. OUTCOMES: Although the context will differ according to specialization, there are essential palliative care skills required of most specialist physicians. General palliative themes identified for focus include symptom management, communication, psychosocial aspects of care, care coordination and access, and myths and pitfalls in palliative care. COMMENT: Specialty trainees' value embedded training in essential themes in palliative care within the context of their training program. The process and results of this project, including the provision of a framework, may be applied to postgraduate training programs in various specialties.

Adaptive practices in heart failure care teams: implications for patient-centered care in the context of complexity.

BACKGROUND: Heart failure (HF), one of the three leading causes of death, is a chronic, progressive, incurable disease. There is growing support for integration of palliative care's holistic approach to suffering, but insufficient understanding of how this would happen in the complex team context of HF care. This study examined how HF care teams, as defined by patients, work together to provide care to patients with advanced disease. METHODS: Team members were identified by each participating patient, generating team sampling units (TSUs) for each patient. Drawn from five study sites in three Canadian provinces, our dataset consists of 209 interviews from 50 TSUs. Drawing on a theoretical framing of HF teams as complex adaptive systems (CAS), interviews were analyzed using the constant comparative method associated with constructivist grounded theory. RESULTS: This paper centers on the dominant theme of system practices, how HF care delivery is reported to work organizationally, socially, and practically, and describes two subthemes: "the way things work around here", which were commonplace, routine ways of doing things, and "the way we make things work around here", which were more conscious, effortful adaptations to usual practice in response to emergent needs. An adaptive practice, often a small alteration to routine, could have amplified effects beyond those intended by the innovating team member and could extend to other settings. CONCLUSION: Adaptive practices emerged unpredictably and were variably experienced by team members. Our study offers an empirically grounded explanation of how HF care teams self-organize and how adaptive practices emerge from nonlinear interdependencies among diverse agents. We use these insights to reframe the question of palliative care integration, to ask how best to foster palliative care-aligned adaptive practices in HF care. This work has implications for health care's growing challenge of providing care to those with chronic medical illness in complex, team-based settings.