Clinical Training Recommendations for Physicians Caring for Patients with Serious Illness

These training recommendations will help physicians address the unique needs of patients living with serious illness.

Examples include physicians working in oncology, cardiology, or primary care

Assess the Needs and Concerns of Patients

• Assess patient’s physical, mental, social and spiritual well-being at all stages of disease
• Know what palliative care is, and when to request a consult

Strengthen the Clinician-Patient Relationship and Understand Goals of Care

• Identify the patient’s surrogate decision-maker
• Have conversations with patients to understand what matters most to them now that they have a diagnosis of a serious illness, and participate in shared decision-making that is aligned with patients’ values and preferences
• Conduct advance care planning conversations and complete advance directives
• Identify how culture, race, gender, sexual orientation, and context (e.g., social determinants of health) influence patient and family decision-making in the context of a serious illness, and deliver responsive, unbiased care matched to needs and priorities
• Identify patients who are eligible for hospice, and support them to make the decision whether to enroll

Manage Pain and Symptoms

• Assess, identify, and treat common symptoms associated with serious illness, including pain; nausea and vomiting; constipation; dyspnea; fatigue; depression; anxiety; delirium and agitation
• Assess the feasibility and safety of the care plan with the patient (e.g., whether prescribed medications are accessible and affordable)
• Assess and identify cognitive impairment
• Refer patients for a specialty palliative care consult for complex or intractable symptoms

Prevent Crises and Plan Ahead

• Recognize non-physical sources of suffering, and refer patients for social work, behavioral health, and/or spiritual support when needed
  • Investigate access to virtual behavioral health support based on patient insurance
• Assess function and refer patients for a home safety and/or fall risk evaluation when appropriate
• Evaluate risks from polypharmacy and anticholinergic burden, and consider de-prescribing as a component of medication management

Complete the Learning Pathway, Foundational Skills for All Physicians, to acquire these skills.

Examples include clinicians working in geriatrics, home-based care, or nursing home settings

Assess the Needs and Concerns of Patients

• Recognize common sources of suffering for patients with serious illness, and perform a comprehensive assessment including:
  • Social risk factors (presence of caregiver; caregiver burden; access to housing, food, and transportation; racism; financial strain)
  • Polypharmacy
  • Emotional and spiritual distress
  • Physical symptom distress (e.g., pain, dyspnea, constipation)
  • Communication barriers (e.g., vision, hearing, language)
  • Need for adaptive equipment

Strengthen the Clinician-Patient Relationship and Understand Goals of Care

• Conduct skilled conversations with patients and families about:
  • Bad news
  • Prognosis
  • Patient/family understanding of the illness

Manage Pain and Symptoms

• Anticipate the full spectrum of symptoms related to specific serious illnesses and along the disease trajectory

Prevent Crises and Plan Ahead

• Identify community resources that can support patients living with serious illness, and their caregivers (either directly or by connecting your patients to a social worker)
• Identify barriers to meeting patient and family needs and honoring their priorities, and discuss the least restrictive alternatives (e.g., home redesign or board and care home versus nursing home placement) either directly, or through referral to the appropriate health professional

Complete the Learning Pathway, Additional Skills for Physicians who Focus Primarily on Supporting People with Serious Illness, to acquire these skills.

Thank you to the following clinicians for their review of these recommendations: Andy Esch, MD, MBA, FAAPM; Diane Meier, MD, FAAHPM