"EXCEL" Meeting Minutes
June 14-15, 2001

LAKE MOREY RESORT, FAIRLEE, VERMONT

 

Present:
Bob Backus, Zail Berry, Fran Brokaw, Patrick Clary, Arnold Golodetz, Marilyn Hart, Judy Hills, Joan Madison, Letha Mills, Denise Niemira, Will Porter, Timothy Quill, Tim Thompson, Bob Tortolani, Ann Albery, Elizabeth Beebe, Sandy Filiault, Jennifer Fitzgerald, Diana Hamilton, Chuck Honsinger, Jennifer Humphrey, Melissa Koll, Marlys Lemnah, Christina Neumann, Joanne Root, Christie Woods, Ann Mitchell, John Campbell, Virginia Fry, Marie Kirn, Lois Lynch, Tasseli McKay

Guest Speaker
Timothy Quill, author of A Midwife through the Dying Process and Death with Dignity, presented a video case history and led a productive discussion of ethical and medical issues around caring for a dying patient.

Organizational Strategy
Tim Thompson opened the meeting by initiating a discussion of ExCEL’s organizational strategy. The issue of bringing more practitioners into active involvement in ExCEL was examined. Denise Niemira suggested charging a nominal membership fee ($5) and electing a steering committee to handle month-to-month business. Letha Mills brought up the need to facilitate reproduction of the work of the Northeast Kingdom, and Tim suggested that ExCEL should continue to develop centralized resources via the website, including standards for care and minutes of local palliative care group meetings. Marie Kirn added that it’s important to encourage an intermediate level of involvement as well, to include people interested in improving end-of-life care who aren’t able to join a committee, as well as people already on the ExCEL list who haven’t been contacted recently. It was suggested that ExCEL develop a list of speakers on end-of-life care statewide. Ginny Fry brought up the possibility of condensing to fewer, better meetings.

VEN Seminars
Arnold Golodetz and John Campbell gave an overview of the Vermont Ethics Network’s advanced care planning seminars. The two-day seminar encourages individuals to become more active in navigating the health care system and in planning for their care. The training is process-oriented, encouraging participants to consider carefully the medical, spiritual, legal and family issues that surround the end of life. Individuals pay $40 for the seminar and receive continuing education credit, a detailed syllabus folder, and a hardbound copy of Handbook for Mortals.

In the coming year, VEN plans to offer gatherings tailored to specific issues, as well as a training series for groups that can’t accommodate the two-day format. Afternoon follow-up planning sessions will be held in each of the six areas that hosted the seminar this past year, and a newsletter and website are in the works.

Fall Newspaper Series
Denise discussed plans for “Finding Our Way: Living with Dying in America,” a 15-week national newspaper article series coming out this fall. The articles will cover topics including palliative care and advance directives, and will be distributed weekly to local newspapers through Knight-Ridder press service. For more information, contact steeringcommittee@bballard.com.

Regional Reports

Bennington:
Letha Mills reported that Barbara Raskin and others have arranged to have Bennington primary care offices distribute information about advanced care planning. The hospital has developed a task force on end-of-life care, which is looking to establish a palliative care program. The group is comparing palliative care units and consult programs, and working in the short term to improve the environment in the room in which patients tend to die. They have held focus groups on recent deaths to get consumer input on the quality of care delivered at the end of the patient’s life. Bennington Hospice, however, is having difficulty getting Medicare reimbursement.

Central Vermont:
Diana Peirce told the group that CVH is reaping the benefits of the palliative care movement in Vermont. Tim Thompson agreed, saying that other areas could learn from Diana’s experience in getting hospice patients early, making it financially sustainable. The hospice census has doubled, and average length of stay has climbed to 62 days. The guideline orders for pain and symptom management developed by ExCEL are in use in the hospital. CVH has a four-person initial consult team, including one doctor and one nurse; they do about six consults per month. There is still some educating to be done, but they are meeting much less resistance than in the past, and have been successful sending patients home out of the intensive care unit. Marilyn Hart reported increasing unofficial consults, and an improvement in pain and symptom management. She noted that as these practices are integrated into normal patient care, consults actually decrease. CVH will be hiring a full-time chaplain in the immediate future.

Chittenden County:
Barb Segal discussed Fletcher Allen’s three-year-old palliative care program, which continues to grow. Since its inception, the program has seen 1500 people, and currently receives 10-20 new consults each week. They do rounds each morning with hematology and oncology, and multidisciplinary teams meet regularly to go over the care of particular patients. Zail Berry lectures twice a month on pain control and end-of-life care, giving the medical students time to examine their recent experiences and decisions; all incoming interns hear a two-hour lecture on end-of-life care. The palliative care program is particularly effective in the intensive care unit, helping patients decide whether to continue aggressive treatment. Denise Adams, a pediatric oncologist, is helping to start a pediatric palliative care unit.

Communications between the hospital and hospice are good. Vermont Respite House is very full, and FAHC also refers significant numbers of patients to Addison, Lamoille, Central Vermont and Champlain Valley. FAHC also meets periodically with Wake Robin staff to deal with residents’ pain control needs.

Joan Madison announced that Barb Segal recently won the prestigious Paul Horton award for excellence in nursing. Barb continues to lecture as an adjunct UVM faculty member, and is also available to speak around the state.

Franklin County Home Health and Hospice:
Marlys Lemnah joked that in St. Albans, hospice is still the “secret service,” although the relationship between the hospital and home care is definitely improving. Symptom management continues to be a priority. Doctors are beginning to be willing to bring concerns over quality of end-of-life care to the Board of Medical Practice. Franklin County Hospice is looking forward to participating in other regional projects after this conference.

Veterans Hospital:
Sandy Filiault said that the VA Hospital has had a hospice suite, complete with kitchen, family and patient areas, for ten years. The suite is used about half of the year for families learning to care for a patient coming home. It is also used for dying patients. Still, many patients die in the intensive care unit, many without families. The hospital has an active palliative care committee. Physical therapists, dieticians, social workers and other practitioners meet once per month to review cases. Every three months, a survey is sent to the families of patients who have recently died. The response rate has been high, and results indicate that pain and symptom management for the dying person are very important to family members. Having pain and symptom management orders electronically has been a big help in this area.

VNH/VNA Hospice:
Marie Kirn reported on progress in VNH/VNA’s service area, which includes five local hospitals, Dartmouth Hitchcock and the VA Hospital. Hospice has become very active in area nursing homes. They are also fairly active in bereavement work, and are planning a new bereavement program with the DHMC chaplaincy. Springfield Hospital has a committee on end-of-life care, and has submitted a grant proposal for an advanced care planning project. Jeff Bell and Dan Caloras are working with the CEO there on this initiative. Hospice is developing good relations with DHMC’s palliative care team. A new palliative care proposal was introduced at Randolph’s medical staff meeting recently.

Mount Ascutney:
It was reported that Mt. Ascutney has formed an interdisciplinary palliative care committee.

DHMC:
Fran Brokaw told the group that the Dartmouth Hitchcock palliative care program is getting lots of new consults from general medicine, oncology and the surgical specialties. Physicians, nurse practitioners, nurses, social workers and chaplaincy hold regular, interdisciplinary team meetings to review cases and plan for care. Six board certified palliative care practitioners, representing a variety of medical specialties, serve on the palliative care team. The hospice patient census is up since January, and a number of hospice workers have been active in the nursing homes. Joanne Root mentioned that DHMC doctors sometimes fail to notify the local physician when they send a patient home to die, and Fran responded that making that contact happen has been a high priority. A committee has formed to consider developing an inpatient hospice unit or hospice house.

Essex/Orleans:
Denise Niemira described the Northeast Kingdom goal of a seamless palliative care system, bringing hospice care to patients dying in nursing home and hospital settings, too. They use a common set of guidelines, standing orders for pain and symptom control, and care plans, all developed through ExCEL. The hospital mission statement already includes palliative care. The palliative care performance improvement committee uses the New Hampshire patient care survey to evaluate the quality of palliative care, and sends another yearly survey to patients’ families. Nurses’ expectations for quality end-of-life care have increased tremendously, and they are working on strategies for dealing with problem physicians.

The committee also worked closely with the CEO to bring the EPEC training to all physicians employed by the hospital, and to get one physician board certified in palliative care. That physician now serves as medical director for several area nursing homes. The DAD grant has helped to diminish the competitive spirit among them, and to make nursing homes an active, well-coordinated force. They are interested in supporting and using respite volunteers, and in making grant-funded projects available to the rest of the community. They have a retreat planned. Joanne Root reported on several innovative projects, including using photography in nursing homes, and bringing music volunteers to nursing homes and hospitals.

Rutland:
Barb Segal reported that Rutland already has a hospice room and is currently applying for a grant to fund its palliative care initiative. Some physicians there may be interested in undergoing board certification in palliative care. In general, Barb noted that they’re meeting less resistance from doctors, but are still having some difficulty stimulating interest in nursing home palliative care initiatives, and in getting hospice workers accepted in nursing homes.

Caledonia:
Linda Johnson discussed several pain management training programs that have taken place over the past year. The trainings, directed primarily at nurses, attracted approximately 250 people each. There is considerable interest among hospital staff in pain assessment, spiritual needs at the end of life, and complementary therapies. The hospital is currently developing a comprehensive pain assessment for all patient charts, and will be conducting a community survey in the fall. Tim Thompson explained that nursing homes have agreed to divide admissions according to emphasis on palliative care or aggressive treatment. They have also become better aware of hospice, and are working actively to keep patients in the nursing home setting and reduce emergency room transports.

Caledonia has had a full-time chaplain for a number of years, who coordinates volunteer hospice services and has mobilized the Christian community in this service. He is well known in the community, and has made a very positive contribution to the quality of end-of-life care.

Addison/Porter:
Diana Peirce explained that Addison County is in the middle stages of a palliative care initiative at Porter Hospital, involving the hospital, home health and hospice, and the local nursing home. Maura McClure has applied to be the Vermont trainer for ELNE.

DAD Grants
Representatives of all four projects funded by the Department of Aging and Disabilities grants met this year. They evaluated ways to mesh the projects and avoid duplication. The group was pleased to conclude that none of the work is duplicative, and in fact, the four projects together form a map for comprehensive, innovative end-of-life care, including advanced care directives, seamless pain control, and quality of life efforts such as “comfort carts.” The period for expenditure of grant funds has been extended to September, and the grantees are anticipating a repeat grant for the coming year with an emphasis on bringing their work to the rest of the state.

Standing Orders
The standing orders committee did not meet this year. The group agreed that since the orders are now two years old, it will be necessary to reconvene to see if the orders are still scientifically valid and well adapted for chart use. Letha Mills suggested that separate orders for pain, nausea and bowel problems might work best. Marilyn Hart observed that shorter-length orders are handier on the chart for nurses. Diana Peirce, Denise Niemira, Marilyn Hart and Letha Mills will serve on the standing orders committee.

Hospital Mission Statements
Arnold Golodetz suggested that this committee has no function currently, because the idea of incorporating palliative care into hospital mission statements is already “out there” and has been approved by the hospital association. Tim Thompson noted that North Country and St. Johnsbury have made appropriate changes to their missions in this regard. It was agreed that this initiative should be pursued exclusively on the local level.

EMS DNR
John Campbell reported that Jeff Bell and Dan Manse at the Health Department continue to work on developing a portable pink DNR order sheet. The sheet would instruct emergency medical personnel to respond to a call with comfort care as defined and no resuscitation. It would be displayed in a person’s home, and travel with the patient to the hospital if necessary. Currently, DNR orders are not honored in transit. This project is awaiting approval by the Commissioner of Health. Once it is approval, ExCEL may help to coordinate publicity through a number of professional associations.

ABHPM and HPCNA Certifications
The committee has been encouraging physicians and nurses to undergo certification with the American Board of Hospice and Palliative Medicine (ABHPM) and the Hospice and Palliative Care Nurses Association (HPCNA), respectively. At this time last year, there were six physicians and 36 nurses with the certification in Vermont; since then six more physicians, all at Dartmouth Hitchcock, have acquired certification. A total of 42 nurses are now certified.

New Committees
A website committee was formed to better develop ExCEL’s website. The site is hosted by the Vermont Medical Society at www.vtmd.org. John Campbell, Ginny Fry and Tim Thompson will work with VMS this year to plan additions to the site. A committee on hospital-based palliative care was formed to share information on hospital palliative care initiatives across the state. Julie Scott (Rutland), Letha Mills (Bennington), Fran Brokaw (Dartmouth Hitchcock), Barb Segal (Fletcher Allen), Sandy Filiault (Veterans Administration), and Denise Niemira (Northeast Kingdom) volunteered to serve on it this year.

ExCEL Communications
To join the list serve call Stephanie Lane at 802-223-7898. If you are already on the list serve type excel@vtmd.org under cc: (not to: ) to send a message to the entire ExCEL list, approximately 36 people. Please note that this list occasionally creates later, duplicate messages from the same sender. The VMS web page is also up with a section for ExCEL. To view this web page go to http://www.vtmd.org and click on ExCEL.

The Steering Committee has been meeting monthly and will continue to meet. They meet every other month in Montpelier and every other month by conference call.