Hospice care and a family practice residency.

Abstract

The percentageof elderly individualsin family physianpractices is growing,which increasestheneed for familyphysiciansto carefor terminally ill patients.AIDS has increasedthe numberof terminallyill youngpeople,and thereis concern that thistrendwill continueoverthe next severaldecades. The Wyoming Valley Family PracticeResidency Programin conjunctionwith Hospice St. Johnhasdevelopeda rotation to betterpreparefamilypractice residentsto carefor terminallyillpatients.HospiceSt. Johnin Kingston, Pennsylvaniais a nonprofithospice operatedby LutheranWelfareServices in Hazleton,Pennsylvania. The program director of the Wyoming Valley Family PracticeResidency servesastheHospiceMedicalDirector, and residentshavebecomeinvolvedin all areasof hospicecare. Educational objectivesfor theresidentsareto become:1) cognizant of theissuesof sufferingin terminallyill patients, 2) adeptin themedicalcare ofterminallyill patients,3) comfortable discussingmedicalissueswith terminally ill patients and their families, 4) awareof the ethical issuesrelatedto the careofterminally ill patients,and5) familiar with the hospiceinterdisciplinaryteam and the waysotherprofessionalshelprelieve suffering in terminally ill patients. Structureof therotation Residentshave experiencesin threemajorareas:theinterdisciplinary team meeting, the patient’s home, and the hospiceinpatient unit. Teammeetingswith residentparticipation are heldweekly. At these meetings,thereis discussionof all newly admittedpatients,patient deaths, andanongoingreviewofactive patients.Nurses,socialworkers, homehealthaides,clergy, administrators,andfacultyphysicianscontribute information each from their perspectiveregardingeach patient andfamily. Specificinterventionsare planned,andprevious interventions areevaluated. Eachresidentisexpectedto make home visits in the companyof the hospicenurse.During thesevisits, theresident seesthepossibilitiesand limitations of home care. The presenceof aphysician,evenif basically as an observer,has been reportedby hospicenursesto be of immeasurablecomfort to patient and family. In the inpatient unit residents function as primary physiciansfor thosepatientswithout an attending physician. Under supervisionof familypracticefaculty, residentsare responsiblefor medicalmanagement and symptom control in patientsadmittedfor respitecareor acutesymptomcontrol. Our experienceconfirms a report in the literature1of a tendencyfor primarycare physiciansto relinquish their patientsto aninstitutional physician ratherthancontinuingas aleaderof the hospiceteam. Residentresponse Residentphysicianshavenoteda variety of experiencesand feelings not typical in a traditional training program.Severalresidentsreported feeling like a family memberor friend after repeatedhome visits. Residentsneedto resistthe idea of cure,andmanyfound it difficult not to respondto signs and symptoms with traditional medical interventions. One residentreportednightmares,andothersrelatedfearsabout their ownhealth. Hospicestaffperspectives The hospice staff has had a generallyfavorable perspectiveon the rotations.Theybelieveresidents havebecomemoreawareofthe care requiredbydyingpatientsandofthe actualprocessof dying. Many residentsseefor the first timea patient die without a multiplicity of tubesin place. Thepresenceof residentshasled to increasedcommunicationbetween hospicestaff and physicians, andnew residentsprovide stimulus to hospice staff to considernew perspectivesandapproaches to care. Severalresidentshave become advocatesfor hospicecare,andnew sourcesof referralwill be developed as residentsgraduateand assume practicepositions. Conclusion Forthepasttwo years,HospiceSt. JohnandtheWyomingValley FamilyPracticeResidencyhavehadamutually beneficial relationship.Residentphysicianshavegainedexperiencein thecareof terminallyill patients and their families. Hospice staffmembershavealsonotedpositive aspectsof the program,and all involvedbelievethattherelationship hasenhancedthe careof terminally ifi patients. Reference 1. Bu]kinW, LukashoxH: Rx for dying: The casefor hospice.NEJMed1988;6:376 William D. Hakkarinen,MD, is ProgramDirectorof theWyomingValleyPamily Practice Residencyand Medical Director of HospiceSt. Johnin Kingston,Pennsylvania.