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Peer Support for Clinicians Having Serious Illness Conversations During COVID-19

Key findings

  • The Peer Serious Illness Conversations Support Team (PSST) was a volunteer team of mostly non-palliative care specialists who had previously been trained in conducting serious illness conversations
  • The PSST offered real-time, confidential assistance to frontline clinicians who were working to clarify values and goals of care with patients across settings from ambulatory care to the ICUs
  • The service was available seven days a week from 7:00 a.m. to 10:00 p.m., and volunteers took calls as they were able; a daily PSST Lead triaged the pages and was available as back up support for clinician volunteers
  • At the peak of the pandemic, volunteers answered up to four calls daily. The average call duration was 13 minutes (range, 3.5–30)
  • This service required only a moderate amount of upfront administrative time and was otherwise a low-cost program

Over the past several years, the Continuum Project at Massachusetts General Hospital has developed and implemented serious illness conversation (SIC) training for non-palliative care providers who work with patients and families facing serious illness in an effort to elucidate the goals, values and priorities patients feel about their care. Prior to the COVID-19 pandemic, this program had trained more than 1,300 non–palliative care clinicians to conduct conversations using the Serious Illness Care Program. When the pandemic arose, the hospital developed the Peer SIC Support Team (PSST) to offer real-time, confidential assistance to frontline clinicians who were working in extraordinary circumstances to help patients clarify values and priorities.

Jeffrey L. Greenwald, MD, a Core Educator Faculty hospitalist in the Department of Medicine and associate director of the Continuum Project, and Juliet Jacobsen, MD, medical director of the Continuum Project and a physician on the Mass General Palliative Care Service, and colleagues describe the design and impact of the service in the Journal of General Internal Medicine.

Recruitment, Training and Resources

In March 2020, the Mass General Continuum Project recruited 44 volunteers. Few were specialists in palliative care, but all were clinicians and had been trained previously in conducting serious illness conversations.

These volunteers became peer supporters for the PSST by attending two one-hour training sessions, specific to pandemic-related emotions and concerns, led by a palliative care attending physician. They were also familiarized with resources compiled by or created for PSST and housed in a web-based system (listed in an appendix to the article).

Each week during the program, peer supporters were invited to join one of two optional, one-hour video calls led by a psychiatrist and psychologist. The groups discussed cases and received support from the leaders and each other.

Organization

The PSST was divided into two adult medical teams, a pediatric team and a mental health team that was available by referral to assist clinicians who needed more substantial or ongoing mental health care. The PSST also included a chaplain, a psychiatrist and members of the palliative care division, who served as resources.

Process

The PSST was available seven days a week from 7:00 a.m. to 10:00 p.m. It was publicized to clinicians in both ambulatory and inpatient settings.

Peer supporters were not expected to be available during all hours of the service. When a clinician paged PSST, the Lead (the individual carrying the PSST pager for the day) triaged the caller to a specific team and sent the team a group text via a messaging app (WhatsApp) that all peer supporters had downloaded onto their phones. Each of the four teams was a separate group within the app.

Once a peer supporter agreed to assist, they received a private text (to preserve the anonymity of the caller) with the details from the original page. If no peer supporter was available within 10 minutes, the Lead took the call.

After the call, peer supporters used the messaging app to share a brief, de-identified summary and the approximate length of the call, and they requested any guidance they wanted.

Administration

A project manager scheduled trainings and peer support groups, ensured the Lead pager was covered, compiled and posted resources and set up and tracked the messaging app groups. The time involved was about 10 hours/week to establish the program and about four hours/week once it was underway.

Evaluation


Number of calls:

  • Average 1.1/day from the start of the service on March 31, 2020 until the peak of the pandemic for the hospital passed in late April (range, 0–4 calls daily with 72% taken by peer supporters and 28% by Leads)
  • 45 calls in total from late March to May 11, 2020
  • 0 afterward until the service was closed on July 3, 2020

17 team members took calls and the average call duration was 13 minutes (range, 3.5–30).

Themes of calls:

  • Documentation (e.g., how to document a change in code status)
  • Care guidance (e.g., how to talk with proxy decision-makers)
  • Distress (e.g., assisting clinicians who witnessed patients dying alone when the family wanted to visit)
  • New roles (e.g., supporting outpatient providers working as hospitalists)
  • Difficult conversations (helping clinicians prepare; debriefing afterward)
  • Medical care (physicians occasionally helped with symptom management or directed calls to palliative care)

Replication

Training materials about serious illness conversations are freely available online, and many hospitals have access to social workers and others with interests and skills in communication who could participate in a service like the PSST. This program could be replicated in other institutions during the COVID-19 pandemic or future crises.

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In a national qualitative study, Massachusetts General Hospital researchers identified innovations in palliative care delivery, staffing, technology and training within emergency departments during the COVID-19 pandemic.

Related

In a project relevant to research during pandemics, Christine Seel Ritchie, MD, MSPH, of The Mongan Institute and Division of Palliative Care and Geriatric Medicine, and colleagues successfully used videoconferencing to include homebound elders and caregivers in 15 meetings of a stakeholder advisory board.