Hospice & Palliative Medicine Clinical Rotations

The Inpatient Palliative Care Consultation Service at BIDMC sees 80-100 new consults per month, and is staffed by 5-6 MDs and NPs every week. Consult requests are diverse, ranging from refractory symptom management to complex goals-of-care conversations, across all floors and specialty services of our academic tertiary care hospital.

We have a unified interdisciplinary team (comprised of specialized MDs, NPs, RNs, SWs, Spiritual Care providers, and Pharmacy members), but the team census is organized by hospital geography (including the innovative Palliative Oncology service, which sees hospitalized patients with cancer as part of a criteria-based referral model). As members of the team, fellows will join daily interdisciplinary team (IDT) huddles, attend clinical and educational conferences, and work closely with a single faculty attending each week, receiving direct observation and feedback with the goal of graduated independence throughout the year.

In their first month at BIDMC, fellows will spend one-on-one time with our Social Work and Spiritual Care staff to learn the diverse perspectives and skills of the interdisciplinary team. In their last month, fellows will educate junior learners with faculty guidance and feedback.

The VA Boston palliative care program serves patients aged 22-100 years with illnesses including cancer, neurological and end-stage cardiac, pulmonary, liver, and renal disease, addressing physical, psychological, social and spiritual domains of care for veterans and families. Veterans are from diverse cultural backgrounds. The Palliative care team is consulted for various decisions which range from goals of care conversations, advance care planning discussions, hospice referrals and end of life care. The fellows will be supervised by a diverse cultural population of physicians who have expertise in Geriatrics, General Medicine, Oncology, Research and Palliative Care. This service sees 40 new patients per month and is staffed by a physician, NP, SW and RN team.

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While on service at the VA Brockton Hospice and Palliative Care Unit, a 15-bed unit located in a long-term care facility at the VA, fellows will round daily on patients with the team, present patients and review the plan of care with the nurse practitioner. Patients on this unit include veterans getting active treatment (e.g., daily radiation for head and neck cancer) and veterans at the end of life with complex symptoms warranting inpatient hospice care. Fellows also have the opportunity to manage patients on the 1-2 bed acute inpatient palliative care/hospice unit while rotating at the West Roxbury VA.

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Fellows will learn to provide longitudinal, ambulatory palliative care through weekly half-day sessions with the Palliative Care Clinic at BIDMC or the Boston VA. Patients at both sites are referred for pain, non-pain symptom management, advanced care planning and psychosocial support. Fellows will see assigned patients during each clinic session under the preceptorship of clinic staff (MD and NP). Fellows will also participate in weekly outpatient interdisciplinary team meetings, and may conduct joint in-person or telemedicine clinic visits with other team members. Our fellows take the lead on communicating recommendations to referring providers, prescribing medications for symptom management, and following up with patients and caregivers by phone when necessary. To improve the longitudinal care experience, patients are booked subsequently with the fellow whenever feasible.

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Fellows will see patients in the long-term care setting as well as the short-term rehab unit (SNF level) for whom palliative care consultations are requested. Long-term care referrals are most often initiated following medical crisis or decline with need to re-address goals of care with unrealistic or conflicted families. Rehab patients are referred following frequent hospital readmissions or a recent decline in function or medical status. With supervision from the HSL team, fellows will assess and manage symptoms, explore goals of care, conduct family meetings and facilitate completion of advance directives, when appropriate. Rounding with the chaplain, attending physician, social worker and psychologist will provide exceptional opportunity to take part in spiritual and religious aspects of care, address end-of-life ethical dilemmas and work with challenging families.

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Good Shepherd Community Care, a free-standing, non-denominational hospice serving the community for over 40 years, is the fellowship’s main site for the home hospice experience. Unique to Good Shepherd are multilingual and multicultural hospice teams dedicated to providing culturally competent end-of-life care throughout greater Boston, including the Krug Zaboty Russian hospice program, the Asian hospice program and the Caminos de Paz Latino hospice program.

During their rotation, fellows will make home visits in conjunction with hospice nurses, the Hospice Medical Director, and with other interdisciplinary team members. Fellows will participate in weekly interdisciplinary team (IDT) meetings, presenting patients they have seen. The didactic curriculum includes lectures on care for the dying patient, non-oral routes of medication administration, and other hospice care topics. Fellows will also learn about key components of hospice administration, including regulatory, administrative, legal, ethical competencies, cost-effective policies, and clinical skills appropriate for hospice care.

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Care Dimensions has provided hospice and palliative care as a leading non-profit organization in the Greater Boston area since 1978. The learning experience includes home visits as well as a rotation at the Care Dimensions Hospice House, a free-standing inpatient hospice facility in Lincoln, MA. Fellows will work closely with a robust interdisciplinary team to learn how to provide compassionate end-of-life care, advanced symptom management, and support for patients and families at the general inpatient (GIP) level of hospice care.

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The Pediatric Advanced Care Team (PACT) at Boston Children’s Hospital is one of the most well-established pediatric palliative care programs in the United States. Fellows will work with the team to provide advanced symptom management, complex medical decision-making, and comprehensive interdisciplinary support to children and families facing serious illness.

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