Monday, August 31, 2009

Interview with Seth Landefeld about Geriatrics and Palliative Medicine Leadership Summit


The John Hartford Foundation supported the inaugural summit of leaders from geriatrics and palliative medicine in July to encourage opportunities, challenges, and next steps for the field. I interviewed Seth Landefeld, chief of Geriatrics at UCSF and San Francisco VAMC, about his experience. Seth Landefeld, Sean Morrison, and Bob Arnold previewed and approved of this post.

On the impetus for the meeting: "The genesis for the meeting occurred 2-3 years ago when we realized that geriatrics and palliative medicine were competing for the same pool of internal medicine residents for fellowship training and that our training should be collaborative, not competitive. In subsequent discussions, we realized that the common ground between the two fields is so much greater than the issue of collaboration in fellowship training. I and several other board members of the American Geriatric Society, including Wayne McCormick, Greg Sachs, and Linda Fried, took this issue to the John Hartford Foundation, which has supported the academic development of both geriatrics and palliative medicine. We asked Chris Langston and Gavin Hougham at the Foundation whether they could help us build the geriatrics-palliative medicine common ground on a national level."

On the structure of the meeting: "Christine Ritchie chaired the planning committee, which included Jean Kutner, Greg Sachs, Bob Arnold, Wayne McCormick, and me. The meeting included the President-elect and key staffers of each organization (Sharon Brangman and Nancy Lundebjerg for American Geriatrics Society and Sean Morrison, Dale Lupu, and Sally Weir for American Association of Hospice and Palliative Medicine), the current President of AAHPM (Gail Cooney), leaders of the Hartford Foundation (Cory Rieder, Chris Langston, and Gavin Hougham) as well as leaders in both fields. We were divided into working groups around education, research, clinical models, leadership, and public policy."

On what was accomplished: "We asked, what is important, and what are the low hanging fruit? Where are the opportunities for collaboration? We created a statement that will be taken to each organization for feedback and support, with the idea of issuing a joint statement in the future. Something along the lines of: both AGS and AAHPM are committed to developing systems that will provide care for patients with advanced illness and their families. We saw opportunities for collaboration in joint fellowships between the two fields. One area of obvious overlap is the care of patients in nursing homes. As we try to conceptualize palliative care as more than just care at the very end of life, one can think of nearly all patients living in nursing homes as being persons who need good palliative care as well as good geriatrics, and yet almost no palliative care programs currently exist in nursing homes. "

On challenges: "One of the challenges will be getting more non-geriatrician palliative care providers interested in and actively committed to working on these issues. It was good that we had people like Janet Abrahm (oncologist and palliative medicine physician), Gail Cooney (neurologist and current AAHPM President) and a few other non-geriatricians from the palliative care field present. We need to reach out to other organizations, such as the American Medical Directors Association (AMDA). We need to make sure we have institutional memory about the work we've accomplished. The turnover of board members of these professional organizations is rapid, whereas the staff of the organizations stays relatively constant. It was important that high level staff members from each organization played leading roles at the meeting."

I'll leave it open to others to comment, only to say I think this idea of a collaborative approach is terrific, and this sort of energy and direction was exactly what led us to create GeriPal in the first place. What do you think about finding common ground between geriatrics and palliative care? What are the tensions and opportunities? What do you consider important, and what are the low hanging fruit?

6 comments:

Eric Widera said...

I would love to learn if there were any real concrete next steps discussed at this meeting; steps that we as a community can take to move this forward. Did they come up with any action plans that we can work on? Or was it just suggested areas of collaboration?

Gavin Hougham said...

The Geriatrics/Palliative Medicine Summit was a terrific example of what motivated leaders with shared interests can accomplish. Seth mentioned a "joint statement" of principles, which is now working its way through the Boards of AGS and AAHPM. This is an important product of the meeting, but additional concrete action steps were also developed in different areas: Education & Training, Research, Public Policy, Clinical Care, and Leadership & Organizational Structure. I expect to see those action plans further developed and implemented through each organization's committee structure. Stay tuned :)

(The John A. Hartford Foundation put up a Grants at Work news piece on the summit HERE.)

Petra said...

I am encouraged to hear that there is interest in more integration between geriatric and palliative care and agree wholeheartedly that nursing home patients would benefit from the joint expertise of geriatric and palliative care.

Unfortunately, palliative care for most nursing home residents is only accessible through hospice care. This leads invariably to "no palliatve care" for those who are not deemed to "die in 6 months" even if they would greatly benefit from a palliative care approach and often duplication of services (Social work, nursing, nurses aides, therapists) for those who are eligible for hospice but do not require a lot of palliation or support, because this is already provided by regular nursing home staff. I hope that more integration will allow for more tailor made approaches of care to the patients' needs rather than being labeled "traditional", "palliative", "geriatric" or "hospice" care.

ken covinsky said...

Petra--i agree with you that the issue of palliative care in the nursing home is a big issue. It seems there are few nursing home patients in whom palliative care should not be a big a part of the care plan. However, many of these patients will not be hospice candidates---either because they do not qualify on prognostic grounds (and this is a population in which the prognostic criteria for hospice makes little sense) or because the patient/family is not ready for hospice.

Getting nursing home patients palliative care outside of hospice often proves difficult. I sometimes wonder if having hospice as a separate service in the nursing home has the unintended consequence of making access to palliative care difficult for nonhospice patients. And for hospice patients, integrating hospice services into the NH care plan can be difficult. There certainly seems to be a need for a more unified approach.

Patrice Villars said...

Petra and Ken,
Great discussion. I think that whether or not the eligibility for hospice and subsequent hospice services (due to artificial medicare imposed guidelines) has the unintended effect of limiting access to palliative care depends on how one defines palliative care. My hope is that the integrative model of palliative care as working along side all other treatment modalities becomes a normal part of care of all patients. Actually a nursing home setting (assuming mostly geriatric pts and geriatric trained staff) may be the ideal place to provide excellent palliative care.

Michael Galindo, MD said...

This is a great and intuitive development in the progress of palliative medicine. I am a BC palliative care doc and often tell people that I'm an "amateur geriatrician" based on affinity, experience, and some extra training in geriatrics.
One thing that combining the two might help with is in the expansion of PC training programs in underserved areas. Here in Utah, we have a crushing lack of training programs. Working together with Geriatrics is likely to be our only way to bootstrap into being able to train new PC doctors, who are sorely needed here.