In This Article
- The Continuum Project began in 2017 to train clinicians on ways to address the unmet needs of patients living with serious illness, to help improve quality of life
- The program has trained over 1,500 Mass General interprofessional clinicians who have documented more than 15,000 serious illness conversations in patients' medical records
- Serious illness conversations should begin early to boost patients' quality of life, combat anxiety and help patients make informed decisions
- Clinicians should document conversations in detail in the medical record so future providers can better understand patients' goals, values, priorities and needs
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A Massachusetts General Hospital program is actively training clinicians in all roles and specialties to deliver more effective palliative care. Through education, documentation tools and community engagement, the Continuum Project aims to address unmet palliative care needs and improve quality of life for patients living with serious illness.
"According to research, only a third of patients living with serious illness have had a conversation with their clinician about their values and goals if they were to become sicker," says Juliet Jacobsen, MD, medical director of the Continuum Project and a physician on the Mass General Palliative Care Service. "The Continuum Project is teaching palliative care communication skills to clinicians throughout the institution and encouraging documentation of serious illness conversations in a centralized module. Using this approach, clinicians can work together to support patients to live as well as possible and to adapt to serious illness."
In less than four years, the program has trained over 1,500 interprofessional clinicians, including physicians, nurse practitioners, nurses, social workers, chaplains, care managers, fellows, residents and medical students. The effort has resulted in more than 15,000 palliative care conversations being documented in patients' medical records.
Filling a Gap in Medical Education
Because palliative care hasn't traditionally been a focus in medical education, many practicing clinicians didn't receive enough high-quality training in the field, says Dr. Jacobsen.
"Our field is working to make medical school education more comprehensive so everybody gets basic palliative care skills—not just as an elective, but something that's built into required coursework," she says. However, it will take time to change that paradigm.
In the meantime, the Continuum Project is taking three proactive approaches to improve palliative care in the Mass General system:
- Implementing the Serious Illness Care Program by training clinicians to have and document serious illness conversations, so that patients' future clinicians can understand what patients know and have been told about their illness
- Engaging the community by providing educational sessions to help patients have discussions with their families and clinicians about what matters most if patients' became sicker, and on how to choose a health care proxy
- Partnering with the Mass General Brigham network to make advance directives such as the health care proxy and MOLST electronic, so that these forms can be more easily accessed by patients and providers
The project's premier strategy—the implementation of the Serious Illness Care Program—has a pair of key goals.
Initiating Serious Illness Conversations Early
The first goal, Dr. Jacobsen says, is making sure serious illness conversations with patients happen early.
"The default is sometimes to talk about the end of life in the last few days or weeks. But we'd like to see clinicians begin to have conversations in the last year or two, so that we can support patients to reflect on their goals and values and live well, with whatever time remains," Dr. Jacobsen says. "When patients have conversations earlier, they feel less anxious and less depressed and report better quality of life. Having conversations earlier actually helps people live better."
Documenting Serious Illness Conversations in the Medical Record
The second goal of the Continuum Project is to help clinicians document serious illness conversations in the medical record. A centralized module in the medical record allows the clinician to record the details of a conversation.
"Our centralized documentation template encourages clinicians to document details about what they talked about with patients, such as the patient's hopes, worries, what matters most if he or she got sicker and even what prognostic information was discussed. If a patient gets sick and is seen in the emergency room or the hospital, other clinicians caring for the patient can understand what was said and have conversations that build on that work," Dr. Jacobsen says.
Overcoming Workflow Barriers
The project also works with clinicians to understand the barriers they might have in discussing and documenting serious illness conversations, and then finds solutions to those challenges. For example, primary care providers (PCPs) are in an excellent position to build rapport and learn about patients' values. But it can be challenging to find time on top of the many other health maintenance tasks required in a visit.
To support PCPs, the Continuum Project created scripts and documentation tools that can help streamline the conversation process. "The script actually keeps people on time. So even though you're having a difficult conversation, you can move through it in 10 or 15 minutes," Dr. Jacobsen says. "The documentation tools are readily available. PCPs can have a conversation with the computer open and document at the same time. This integrates serious illness conversations into the workflow."
Meeting Clinicians Where They Are
Clinicians can learn from the Continuum Project in several ways. Even without communication training, clinicians can simply use the documentation module in the medical record. They can also access conversation guides for several specialties, such as oncology, pediatrics and memory disorders, as well as primary care in English and Spanish.
The project offers a 90-minute virtual communication training on zoom which incorporates role-play with actors. Previous participants have also conducted and published research based on what they learned and implemented.
"We work with people at every level of availability to help move these efforts forward," says Dr. Jacobsen. "When we work with a group, we often look for champions within that group who help lead change efforts. They attend a two-week training, then go back to their practice and get people excited about this work, building consensus that these conversations are important."
The Pendulum of Prognostic Awareness
In addition to training clinicians to have and document serious illness conversations, Dr. Jacobsen also hopes to impart another key message to clinicians.
"The way patients and families cope with serious illness is like a pendulum. There are moments of hopefulness and optimism. Sometimes people think of that as denial, but it's actually hope. And then there are moments of being more realistic or thinking about the future or being sad. A healthy way to live with a serious illness is to move back and forth," she says. "Our job as clinicians is to help patients maintain hope and live as well as possible while also helping them prepare for whatever might lie ahead with their illness, so that they are ready when medical decisions arise."
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