It’s a delicate dance that many young health care professionals feel they don’t do well: talking to patients and their families about the important topic of advance care planning.
Leah Millstein, MD, of the University of Maryland School of Medicine, once felt that way. It eventually led her to apply for and receive a University of Maryland, Baltimore (UMB) Interprofessional Education (IPE) seed grant to design a project that would help doctors and nurses feel more at ease when discussing advance care directives and living wills with patients.
UMB President Jay A. Perman, MD, and School of Nursing Dean Jane M. Kirschling, PhD, RN, FAAN, director of the UMB Center for Interprofessional Education (IPE), fourth and fifth from left, with other leaders of the center and faculty members who were recipients of IPE seed grants.
Millstein shared her story, and the results of her seed grant project, “Interprofessional Approach to Advance Care Planning,” at the IPE 2017-2018 Seed Grant Symposium on Dec. 13 at the Southern Management Corporation Campus Center. Five other teams also presented the results of their IPE seed grant projects.
“It was a very challenging family,” Millstein recalled. “The patient had Parkinson’s and could not easily communicate his own wishes. The daughter and stepmother were not seeing eye to eye, and I was lucky to have the opportunity to be able to work with a social worker.”
A longstanding meeting was set up that included Millstein, the social worker, a neurologist, and the family.
“It really opened my eyes as to how much easier this was to do as a team, when I was really struggling to get anywhere with the family by myself,” she said. “And I wanted residents, and then students, to have the same opportunity that I found about how valuable it was to my own clinical experience.”
There is a national growing emphasis on advance care planning, end-of-life care, and advance directives, explained Millstein. An advance directive is a document with which a person makes provisions for health care decisions in the event that, in the future, he or she becomes unable to make those decisions.
“But there’s no increase in training for students or residents or other members of the medical health care team who are generally thought of to be the initiators of this conversation,” she noted. “And we see more and more that advance care planning is happening in response to end-of-life situations, which, obviously, is not the point of the terms advance planning.”
A 2003 national report evaluating advance care planning demonstrated gaps in both student and resident comfort in providing care to the dying as well as faculty and resident discomfort in teaching those topics. A similar poll in 2016 of more than 700 physicians “really demonstrated that things hadn’t gotten any better and that there was a lack of formal training and uncertainty amongst physicians in how to communicate with patients,” Millstein said.
Her IPE seed grant project, which included students from the schools of medicine, social work, and nursing, was aimed at enhancing knowledge and comfort of medical, social work, and nursing students on the critical topic of advance care planning, while also providing them with firsthand experience of multidisciplinary collaboration and, specifically, team-based care delivery.
“We wanted to provide students as early learners with these skills because they’re going to be in these situations throughout their careers,” Millstein said, “and we wanted them to have an initial baseline of skills and comfort with this to make it something that was more likely to be talked about whenever the opportunity arose.”
Over the course of the 2017-2018 academic year, students involved in the project were educated on various advance care planning topics during an educational seminar administered by faculty from the schools of medicine and social work. Students collaborated in an interdisciplinary clinical encounter dedicated to advance care planning at the University Health Clinic. The students’ experiences were assessed with a series of surveys, with the expectation that participation will improve the students’ comfort and ability to address advance care planning.
The team began by assessing the current state of advance directive completion in the outpatient internal resident medicine clinic. They looked at 291 patient charts. Of those, 269 met the team’s inclusion criteria, and only three of those 269 had a documented advance directive on file as part of their electronic medical record.
“That was a rate of 1.1 percent, which demonstrates that this is not being done,” Millstein said.
Internal medicine residents worked with the same social worker Millstein had earlier befriended and family members to discuss advance care planning and had students observe the interactions.
Many of the students said they had no experience in advance care planning and rated their ability to break bad news and facilitate conversations about advance directives as “pretty poor,” Millstein said. At the end of the grant project, “We had outcome improvement in all areas,” she added.
UMB has placed a high priority on IPE, and its importance is recognized in the University's 2017-2021 Strategic Plan. During opening remarks, UMB President Jay A. Perman, MD, said team-based care is better care for patients and providers alike. “It results in better outcomes with greater satisfaction on the part of patients and greater satisfaction on the part of those of us who provide care” he said.
The seed grant symposium began with opening remarks from Perman, who gave credit to Jane M. Kirschling, PhD, RN, FAAN, director, Center for Interprofessional Education, and dean of the University of Maryland School of Nursing.
“She’s the person who keeps this alive, this onward and upward march that we insist on here at UMB in developing the right way to teach interprofessional health care delivery and the right way to deliver interprofessional health care delivery,” Perman said. “Most importantly, I need to thank everybody in this room for your commitment to exploring and expanding this vision of team-based health care. What you are doing with the seed grants that you successfully competed for is to do something that is exceedingly necessary in growing team-based care as an important model for health care delivery. Please know how interested and proud I am of the work that you are doing.”
The Center for Interprofessional Education is a national leader in providing interprofessional education for health, law, and human services professionals that is grounded in best practices for educational innovation and assessment. A hallmark of the center is education that improves health care and human service delivery resulting in enhanced well-being.
A list of the projects and team members:
A new era of “See one. Do one. Teach one.” Using an Interprofessional Education Module to Learn, Teach, and Optimize the Treatment of Sepsis
Nirav Shah, MD, FCCP – School of Medicine
Jeffrey Gonzales, PharmD, FCCM, BCPS, BCCCP – previously School of Pharmacy
Joan Davenport, PhD, RN – School of Nursing
Renee Dixon, MD – School of Medicine
Mojdeh Heavner, PharmD, BCPS, BCCCP – School of Pharmacy
Samuel Tisherman, MD, FACS, FCCM – School of Medicine
Tracey Wilson, DNP, ACNP – School of Nursing and University of Maryland Medical Center
Siu Yan Amy Yeung, PharmD – School of Pharmacy and University of Maryland Medical Center
Building The University of Maryland, Baltimore’s Interprofessional Continuing Education Capacity (IPCE)
Patricia Franklin, PhD, RN – School of Nursing
Seante Hatcher, LCSW-C – School of Social Work
Jason Noel, PharmD, BCPP – School of Pharmacy
Chanise Reese-Queen, CMP, MSA – School of Medicine
Anita Tarzian, PhD, RN – Schools of Nursing and Law
Expansion of Interprofessional Education (IPE) Clinics in Montgomery County, MD
Gina Rowe, PhD, DNP, MPH, FNP-BC, PHCNS-BC, CNE – School of Nursing
Heather Congdon, PharmD, BCPS, CDE - School of Pharmacy
Claire Engers, JD, MSW, LCSW-C – School of Social Work
Talia Gimeno, LCSW-C - School of Social Work
Jana Goodwin, PhD, RN, CNE – Mercy Health Center
Kate Morris, LCSW-C - UMBC at USG
Barbara Nathanson, LCSW-C – School of Social Work
Joan Pittman, PhD, MSW, LCSW-C – School of Social Work
Rhonique Shields – Holy Cross Health
Interprofessional Approach to Advance Care Planning
Leah Millstein, MD – School of Medicine
Amanda Agarwal, LCSW-C – University Health Clinic
John Allen, MD – University of Maryland Internal Medicine Residency
Danielle Baek, MD – School of Medicine and University Health Clinic
Mel Bellin, PhD, LCSW – School of Social Work
John Cagle, PhD, MSW – School of Social Work
Joan Davitt, PhD, MSW, MLSP – School of Social Work
Steven Eveland, MBA, RN, CHPN – University of Maryland Medical Center
IPE Care in Geriatrics – Expanding Opportunities of Aging in Place Program (UMB_APP) in West Baltimore
Nicole Brandt, PharmD, MBA, BCPP, CGP, FASCP - School of Pharmacy
Reba Cornman, MSW – School of Social Work
Kelly Doran, PhD, RN – School of Nursing
Sarah Dee Holmes, MSW – School of Social Work
Daniel Mansour, PharmD, BCGP, FASCP - School of Pharmacy
Barbara Resnick, PhD, CRNP, FAAN, FAANP - School of Nursing
Norman Retener, MD – School of Medicine
Bernadette Siaton, MD – School of Medicine
Everett Smith, LGSW – School of Social Work
Building a High Reliability Organization – Interprofessional Development for Safer Care
Mangla Gulati, MD, CPPS, FACP, SFHM – School of Medicine
Alison Duffy, PharmD, BCOP – School of Pharmacy
Emily Heil, PharmD, BCPS-AQ ID, AAHIVP – School of Pharmacy
Deborah Schofield, PhD(c), DNP, CRNP, FAANP - UMMC and School of Nursing
Kerri Thom, MD, MS – School of Medicine