STATE OF THE DIVISION:

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DPC Grand Rounds June 14, 2012
STATE OF THE DIVISION An Update on the past,
present future of the DIVISION OF
PALLIATIVE CARE
Jeff Myers MD, CCFP, MSEd W. Gifford-Jones
Professorship in Pain and Palliative Care Head
and Associate Professor - Division of Palliative
Care, Department of Family and Community
Medicine Faculty of Medicine, University of
Toronto
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DIVISION OF PALLIATIVE CARE

• Who are we?
• What does being a DPC Member mean?
• What do we do?
• Why do we matter?
• Where are we going?
• How will we get there?
• What can each of us do?

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DPC WHO ARE WE?

• The core purpose of the DPC is to create and
  support a community of learners, teachers,
  innovators, researchers and practitioners working
  together to improve the quality of palliative and
  end of life care for patients and their
  families.

DPC Strategic Plan, 2009
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DPC WHO ARE WE?

• The values serving to guide
• all DPC activities are
• Interprofessionalism
• Community
• Innovation
• Advocacy

DPC Strategic Plan, 2009
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The largest academic palliative care division in
Canada!!!
DPC WHO ARE WE?
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DPC WHO ARE WE?

• 2002 Residency Program
• 2007 Formal status as an academic Division
  (Head, Dr. Larry Librach, 2007-11)
• 2009 Inaugural Strategic Plan Long Term Vision
• Every health care professional trained
  through the U of T will be able to
  demonstrate basic competencies in the
  provision of quality palliative and EOL care
• DPC will be a leader in developing,
  measuring and teaching advanced
  competencies in palliative care in Canada

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DPC WHO ARE WE?

• Long Term Vision
• A robust and collaborative research program will
  be credited with discoveries that challenge
  current best practice in care provision and
  education and explore innovative interventions
  that improve the quality of palliative and EOL
  care
• Professionals seeking a location for clinical
  practice, research and/or education in palliative
  care within an expansive, dynamic environment
  will choose Toronto and the DFCMs DPC

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DPC ORG STRUCTURE
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DPC COMMITTEE LEADS

• CPD Lead Monica Branigan
• RPD Giovanna Sirianni
• Interim RPD James Downar
• Education Co-Leads Anita Chakraborty
• Monica Branigan
• Research Co-Leads Amna Husain
• Paolo Mazzotta
• Admin Lead Heather Huckfield

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DPC PROFESSION / DISCIPLINE LEADS

• Social Work Susan Blacker
• Nursing Sharon Reynolds
• Pediatrics Adam Rapaport

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DPC SITE REPS

• Baycrest Daphna Grossman
• CVH Manisha Sharma
• Markham Stouffville Gina Yip
• Mt Sinai Russell Goldman
• NYGH Niren Shetty
• PMH Julia Ridley
• Scarborough Larry Zoberman
• SickKids Adam Rapaport

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DPC SITE REPS

• Southlake Cindy So
• St. Josephs Carol Hughes
• St. Michaels Ignazio LaDelfa
• Sunnybrook Dori Seccareccia
• TEGH Kevin Workentin
• TGH/TWH Sharon Reynolds
• Trillium Tony Hung

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DPC MEMBERS

• Membership Assembly
• Current composition
• Over 60 Faculty Members
• Over 60 Associate Members

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DPC WHAT DOES BEING A MEMBER MEAN?

• FACULTY MEMBERS
• Clinicians who have pursued and achieved a U of
  T faculty appointment
• Available to all professionals who are members
  of a U of T affiliated institution and actively
  involved in palliative care and teaching,
  education, research, creative professional
  activity and/or leadership

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DPC WHAT DOES BEING A MEMBER MEAN?

• ASSOCIATE MEMBERS
• Clinicians without a formal clinical or faculty
  appointment with the U of T who have an interest
  and/or a clinical practice involving palliative
  care

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DPC MEMBERSHIP WHY?

• Participate in DPC related activities,
  initiatives and committees (eg. PD,
  teaching/education, research, clinical,
  operations, administrative, social networking)
• Contribute to building a sense of academic
  community
• Be informed about DPC related activities and
  initiatives
• Connect/collaborate with colleagues across the
  DPC
• Cultivate a profession specific community
• Gain exposure to and develop skills related to
  professional and/or academic activities
• Collaborate on profession specific
  projects/initiatives
• Opportunities to explore formal and informal
  mentorship

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DIVISION OF PALLIATIVE CARE

• WHAT DO WE DO?

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DPC WHAT DO WE DO?

• We Educate
• 95 of DPC Members are involved in teaching and
  education activities

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DPC WHAT DO WE DO?

• Undergraduate Medicine
• Pre-clerkship
• Pain Week MMMD course Approaching End Of
  Life ASCM
• Clerkship
• Anesthesia, General Surgery, Family Medicine,
  Transition to Residency, FMLE

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DPC WHAT DO WE DO?

• Postgraduate Medicine

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DPC WHAT DO WE DO?

• Postgraduate Medicine Enhanced Skills
• Clinical Palliative Care Enhanced Skills Program
• St. Josephs Health Centre Site
• 12 graduates since 2005
• North York General Hospital Site
• Conjoint Palliative Medicine Residency Program

Recently implemented
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CONJOINT RESIDENCY PROGRAM
Annual Growth in of Positions and Applicants
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CONJOINT RESIDENCY PROGRAMGRADUATES
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DPC WHAT DO WE DO?
CE PD
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DPC WHAT DO WE DO?

• We Educate - Innovations
• Centre for IPE - Case Based Session
• PGCoreEd
• Social Work Interest Group - Susan Blacker
• National Learner Assessment Collaborative
• CVH/Trillium - collaboration with FHT (LEAP)
• Collaboration with Cicely Saunders Institute
• Medical Student Exchange Fellowship
  (Dr. Robert Buckman)

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DPC WHAT DO WE DO?

• We Discover
• Over 50 publications
• in last five years
• Dr. Amna Husain PI for
• CIHR Grant Ranked 1

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DPC WHAT DO WE DO?
A few examples
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DPC WHAT DO WE DO?
A few examples
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DPC WHAT DO WE DO?

• We Are Acknowledged
• 2011 Undergraduate New Teacher Award Dr. Jean
  Hudson
• 2010 Helen P. Batty Award Dr. James Meuser
• 2010 DFCM Awards of Excellence Dr. Monica
  Branigan
• 2010 PD Program Excellence Award Dr. Kevin
  Workentin
• 2010 PD Program Dr. Pauline Abrahams
• 2009 John W. Bradley Educational Admin Dr. Dori
  Seccareccia
• 2009 Postgraduate Education Program Dr. Leah
  Steinberg

A few examples
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DPC WHAT DO WE DO?

• We Are Acknowledged
• Senior Promotion to the Rank of Associate
  Professor
• 2012 Dr. Albert Kirsen Dr. Vince Maida
• 2011 Dr. Monica Branigan, Dr. Amna Husain Dr.
  Jeff Myers
• 2010 Dr. Jamie Meuser

A few examples
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DIVISION OF PALLIATIVE CARE

• WHY DO WE MATTER?

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DPC WHY DO WE MATTER?
The MOH says so
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DPC WHY DO WE MATTER?
The care we provide makes a difference
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DPC WHY DO WE MATTER?
We are catching on in other settings
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DPC WHY DO WE MATTER?

• Conclusions
• Our prospective study shows that dementia is a
  terminal illness and furthers our knowledge of
  the clinical complications characterizing its
  final stage.
• This was the first time this statement was made

We are catching on in other settings
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CLINICAL COURSE DEMENTIALETTER TO THE EDITOR
DPC WHY DO WE MATTER?

• Classifying all seniors affected by advanced
  dementia as terminally illcan become a gateway
  to therapeutic neglect."

We are catching on in other settingsand familiar
challenges lie ahead
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DPC WHY DO WE MATTER?

• A request was recently made of me to speak to
  the topic
• How to initiate and have end-of-life
  discussions in the office for patients with
  palliative conditions?

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DPC WHY DO WE MATTER?

• A request was recently made of me to speak to
  the topic
• How to initiate and have end-of-life
  discussions in the office for patients with
  palliative conditions?

How might this be more precisely worded?
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DPC WHY DO WE MATTER?

• A request was recently made of me to speak to
  the topic
• How to initiate and have goals of care
  discussions in the office for patients with
  advanced and/or incurable

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DPC WHY DO WE MATTER?

• A request was recently made of me to speak to
  the topic
• How to initiate and have goals of care
  discussions in the office for patients with
  advanced and/or incurable
• Propose this to be a primary solution to
  effectively addressing the tsunami of chronic
  disease

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Actual and Projected Deaths in Ontario 1996-2036
WE ARE HERE!!!
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DIVISION OF PALLIATIVE CARE

• WHERE ARE WE GOING?

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DPC WHERE ARE WE GOING?

• SUB-SPECIALTY STATUS
• Currently, the RCPSC application process for
  formal recognition of Palliative Medicine as a
  Sub-Specialty is in Stage 2 (Consultation Phase)
• New two-year medical training program
• Routes of entry are IM, Neuro, Anesth for Adults
  stream and Peds
• Uncertain what the current one-year program will
  evolve in to as per CFPC

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DPC WHERE ARE WE GOING?

• If/when a Sub-Specialty is formally created, the
  route of practice eligibility will likely be
  made available to physicians who have both
  completed the current one-year program and
  entered from a RCPSC specialty as well as current
  RCPSC members who maintain a clinical practice
  focused in Palliative Medicine
• Discussions at the CFPC are currently underway to
  determine if a certification and/or designation
  process will be instituted for the one-year
  program

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DPC WHERE ARE WE GOING?

• Based on what is determined, a practice eligible
  route is likely to be made available to current
  CFPC members who maintain a clinical practice
  focused in Palliative Medicine (with or without
  having completed the one-year training program)
• Family physicians who do not hold certification
  can acquire certification until December 31, 2012
  via Alternate Route to Certification - see
  cfpc.ca

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DPC WHERE ARE WE GOING?
Curative / Remissive Therapy
CG Support Bereavement

Presentation
Death
EOL Care
Hospice Palliative Care
Model of Collaborative or Shared Care
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DPC WHERE ARE WE GOING?
Curative / Remissive Therapy
CG Support Bereavement

Presentation
Death
EOL Care
Hospice Palliative Care
Model of Collaborative or Shared Care Its
time to move beyond this
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LEVELS OF PALLIATIVE CARE

• Most will have needs requiring only basic PC
  skills (Pt A)
• Others will occasionally require specialty level
  PC (Pts B, D)
• A small number with highly complex needs will
  indefinitely require specialty level PC
  (Pts C, E)

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PROVISION OF PALLIATIVE CARE
Academic Mandate Patient Volumes Description of Patient Needs Levels of Care Expertise Description of Provider Role Care Setting
Complex needs unresponsive to basic care or established protocols Require highly individualized care plans Experts in PC consults to secondary and primary level providers Leaders in PC research education All care settings require at least access to tertiary level expertise generally hospital based
PC needs exceed those available from primary care Pt/families ability to cope is compromised Extensive PC knowledge in PC model of care may be consult only to direct care most often share care with primary team Required in all care settings (home, acute care, LTC, CCC ambulatory clinics)
Largest group of patients Most needs met through primary care providers (i.e. non-PC specialists Basic or primary level PC related clinical skills (pain and Sx Mx basic psycho-social care) All care settings
Tertiary Level
Secondary Level PC Expertise
Primary Level PC Expertise
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PROVISION OF PALLIATIVE CARE
Academic Mandate Patient Volumes Description of Patient Needs Levels of Care Expertise Description of Provider Role Care Setting
Complex needs unresponsive to basic care or established protocols Require highly individualized care plans Experts in PC consults to secondary and primary level providers Leaders in PC research education All care settings require at least access to tertiary level expertise generally hospital based
PC needs exceed those available from primary care Pt/families ability to cope is compromised Extensive PC knowledge in PC model of care may be consult only to direct care most often share care with primary team Required in all care settings (home, acute care, LTC, CCC ambulatory clinics)
Largest group of patients Most needs met through primary care providers (i.e. non-PC specialists Basic or primary level PC related clinical skills (pain and Sx Mx basic psycho-social care) All care settings
Tertiary Level
Secondary Level PC Expertise

Primary Level PC Expertise
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DIVISION OF PALLIATIVE CARE

• WHERE ARE WE GOING AND HOW WILL WE GET THERE?

OUR initial strategy will be to BUILD CAPACITY
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DPC HOW WILL WE GET THERE?

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DPC HOW WILL WE GET THERE?

• It should not be advocacy for
• earlier integration of the PC field
  in the illness trajectory
• It should be advocacy for earlier integration of
  both PC philosophy and PC-related clinical
  skills

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If oncology has just recently integrated
palliative care-related clinical skills in to
their training programs, what about every other
illness known to be incurable and the IP teams
who care for them?CHF, COPD, Dementia, ND,
CKD, cirrhosis, metabolic disorders
DPC HOW WILL WE GET THERE?
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Actual and Projected Deaths in Ontario 1996-2036
WE ARE HERE!!!
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HOW WILL WE BUILD CAPACITY?INTEGRATION
EDUCATIONCOMMUNITY BUILDING
DPC HOW WILL WE GET THERE?
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DPC INTEGRATION

• BEGIN WITH DFCM
• DPC Head Site Visits
• Faculty Appointments Collaborative Model with
  Site Chiefs
• DPC A Resource for DFCM Faculty
• Next four slides outlines possible elements
• DFCM Site Integration Tool Kit

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DPC INTEGRATION

• DFCM Site Integration Tool Kit
• Examples of possible standard presentations
• The DPC As A Resource to the DFCM How to Have a
  Discussion with the DFCM Chief
• Strategies for Teaching Your Family Medicine
  Colleagues
• The Palliative Care Youre Providing But May Not
  Know It Building Capacity Among Family MDs
• As well, presentations on topics from brochure

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DPC EDUCATION

• Repository of resources
• Resources for community building through
  collaborations and sharing
• Resources for Learners
• Resources for Teachers
• undergrad, postgrad, IPE, CE, other prof
• Resources for Researchers
• Resources for Leaders
• Patient and Family Education Resources

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DPC COMMUNITY BUILDING

• DPC Face to Face Event - Sept/Oct 2012
• DPC New Member Orientation
• DPC FAQs (What, Who, Where, Why, How)
• Value-add vehicle supporting collaboration

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DPC WHAT CAN EACH OF US DO?

• THIS IS A CALL TO ACTION
• Each of us MUST consider ourselves an essential
  resource
• Every professional interaction MUST have two
  components
• CLINICAL AND EDUCATIONAL

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DPC WHAT CAN EACH OF US DO?

• For EVERY professional interaction
• Contribute thoughtfully
• Be willing to teach
• Be precise vigilant with your words

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DPC WHAT CAN EACH OF US DO?

• Each of us MUST view ourselves as leaders,
  ambassadors educators as well as be thoughtful
  in
• How we contribute eg. discussions re Care
  delivery models
• How we view consultations and referrals as more
  than JUST patient/family care but as
  opportunities to educate our colleagues
• What can I teach, to whom, how and will my
  response differ next time?

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DPC PRECISION WITH OUR WORDS

• With vigilance and respect, seek clarification,
  correct inaccuracies teach colleagues,
  learners, family members, friends
• What do you mean byterminal?
• What do you mean bypalliative?
• Oh you mean her illness is incurable.
• Whats her performance status and level of
  function as well as goals for her care?

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DPC PRECISION WITH OUR WORDS

• With vigilance and respect, seek clarification,
  correct inaccuracies teach colleagues,
  learners, family members, friends
• Jeff, can I talk to you about a referral we have
  made to pain clinic?
• Nope. But happy to speak about a referral made
  to palliative care clinic. Did you tell the pt
  she was being seen in palliative care clinic?

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DPC OUR TIME IS NOW!!!

• Who are we?
• What does being a DPC Member mean?
• What do we do?
• Why do we matter?
• Where are we going?
• How will we get there?
• What can each of us do?

jeff.myers_at_sunnybrook.ca