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Insights on IOM’s Dying in America Report

For patients and their loved ones, no care decisions are more profound than those made near the end of life. For the millions of Americans who work in or with the health care sector—including clinicians, clergy, caregivers, and support staff—providing high-quality care for people who are nearing the end of life is a matter of professional commitment and responsibility. Health system managers, payers, and policy makers, likewise, have a responsibility to ensure that end-of-life care is compassionate, affordable, sustainable, and of the best quality possible.

      – Dying in America, IOM Report Brief, September 2014

Over the past year and a half, I had the privilege of serving on the Institute of Medicine’s Committee on Approaching Death: Addressing Key End-of-Life Issues, along with fellow AAHPM members, Patricia Bomba, Eduardo Bruera, Pamela Hinds, Diane Meier, Judith Peres, Christian Sinclair, Joan Teno and James Tulsky. The outcome was the development of the now well publicized report, Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life. It is the first report in nearly two decades to address the care of individuals with serious illness and their families – the care you and I provide each and every day. The study concluded that “improving the quality and availability of medical and social services for patients and their families could not only enhance quality of life through the end of life, but may also contribute to a more sustainable care system.”

For those of you who don’t have time to read the full report, here are a few highlights of some of the key recommendations::

  • Government health insurers and care delivery programs as well as private health insurers should cover the provision of comprehensive care for individuals with advanced serious illness who are nearing the end of life. Comprehensive care should
    • be seamless, high-quality, integrated, patient-centered, family-oriented, and consistently accessible around the clock;
    • consider the evolving physical, emotional, social, and spiritual needs of individuals approaching the end of life, as well as those of their family and/or caregivers;
    • be competently delivered by professionals with appropriate expertise and training;
    • include coordinated, efficient, and interoperable information transfer across all providers and all settings; and
    • be consistent with individuals’ values, goals, and informed preferences.
  • Care should be characterized by transparency and accountability through public reporting of aggregate quality and cost measures for all aspects of the health care system related to end-of-life care, including quality reporting for advance care planning and communication.
  • All people with advanced serious illness should have access to skilled palliative care or, when appropriate, hospice care in all settings where they receive care.
  • Educational institutions, credentialing bodies, accrediting boards, state regulatory agencies, and health care delivery organizations should establish the appropriate training, certification, and/or licensure requirements to strengthen the palliative care knowledge and skills of all clinicians who care for individuals with advanced serious illness who are nearing the end of life. All clinicians who care for people with advanced serious illness should be competent in basic palliative care, including communication skills, interprofessional collaboration, and symptom management;
  • Federal, state, and private insurance and health care delivery programs should integrate the financing of medical and social services to support the provision of quality care consistent with the values, goals, and informed preferences of people with advanced serious illness nearing the end of life.
  • Civic leaders, public health and other governmental agencies, community-based organizations, faith-based organizations, consumer groups, health care delivery organizations, payers, employers, and professional societies should engage their constituents and provide fact-based information about care of people with advanced serious illness to encourage advance care planning and informed choice based on the needs and values of individuals.

The report concludes with a reminder that “a person-centered family-oriented approach that honors individual preferences and promotes quality of life through the end of life should be a national priority.” I couldn’t agree more.

These recommendations include action items for everyone – for us as individual clinicians, for us as leaders, for our health care delivery and educational organizations and professional organizations, for legislative and regulatory bodies, for payers, and for individuals and families. How will you act on these findings and recommendations? Have you shared it with your colleagues, the executives in your organization, your legislators, your community organizations? Have you talked with the press? I encourage you to offer your thoughts and reactions to, and how you are leveraging and publicizing, the IOM Report in the comments section of this blog post. The discussion will help us improve the care of our seriously ill patients and their families through the thoughtful work of AAHPM and our respective organizations.

Jean S. Kutner, MD MSPH FAAHPM
AAHPM President

What is the difference between Coaching, Mentoring, Counseling, Training and Managing?

by William “Marty” Martin, PsyD MA MPH MS CHES

ACPE faculty member William “Marty” Martin presented a focused session on Coaching and Mentoring at the AAHPM Leadership Forum: Ascend program, September 14-16, 2014. AAHPM Ascend is a new intensive program included in the AAHPM’s comprehensive new Leadership Forum.

Palliative care/hospice leaders must be able to coach, mentor, counsel, train and manage depending upon the individual and situation. How do I know when I’m doing what? Before differentiating each one of these, all of these share the following in common: communication; interpersonal sensitivity; and relationships. The focus of a coach is to guide others by asking questions and structuring a process for that individual to achieve his/her goals. In comparison, a mentor may also guide others in achieving their goals but mentoring is less focused on performance and specific tasks. Mentoring has a broader focus than coaching. Mentoring emphasizes both the professional and personal development of the individual.

Counseling seeks to explore the underlying dynamics of individuals and their relationships. Counselors and coaches both ask questions but counselors tend not to address tasks and performance. The goal for counseling is to promote self-understanding and self-acceptance.

Training is all about the acquisition and mastery of knowledge and skills. As a trainer, you must rely upon other tools other than asking questions such as lecturing, giving feedback on assignments, and in some cases, offering evaluative feedback.

Finally, as a manager, the aim is to assure that the individual “does his/her job” or “fulfills his/her contractual duties.” In reality, if you are a physician leader, then you function as a coach, mentor, counselor, trainer and manager. You want to be sure you give a clear signal to the other individual to reduce any role confusion and role conflict.

Leaders Set the Tone

By Kevin E. O’Connor, CSP

ACPE faculty member Kevin E. O’Connor, CSP, presented focused sessions on Relationship Building and Change Management at the AAHPM Leadership Forum: Ascend program, September 14-16, 2014. AAHPM Ascend is a new intensive program included in the AAHPM’s comprehensive new Leadership Forum.

People crave two things: they want to feel connected and included. Instead of jumping headfirst into the content of your information, take time to make sure your listeners feel at home with you and their surroundings.

Create the atmosphere right from the beginning with your introductions and opening. Be enthusiastic, but maintain your calm as you begin to give directions.

Make sure you introduce key participants and define their role in the group. Clearly set out the agenda and overall goals for the meeting.

An audience who feels welcome and included will work harder to reach positive outcomes under the guidance of you, their leader. Here’s how to settle them in.

  • Always suggest, never demand. “Consider XYZ” instead of “Clearly, XYZ presents the most effective option.”
  • Question. Lace your presentation and their discussion time with relevant questions. “In your clinical experience, what three areas proved most important?”
  • Review. Guide them through their own learning. Use a flipchart to post statements. “What do these points mean to you?” Discussion always ensues.

Managing Fear and Bad News

How very little can be done under the spirit of fear.
Florence Nightingale, nurse

When we label fear as fear, it controls us. Be wary of how fear can outmatch the goal. When you deliver unpleasant news or when you face a hostile client or group, make sure you prepare them for what you have to say.

  • Frame your message in terms of their concerns, even if you need to be focused on a specific topic.
  • Revitalize the group’s energy by allowing them to share the things they worry about – professional and personal implications.
  • Avoid letting the “we” become “me.”
  • Capture the power of metaphors. Has someone used an image you can piggyback off? Are you climbing a mountain together? Hurdling an obstacle?

Leaders Take Risks.
Successful leaders understand that risk taking is an essential component to a fulfilling career. The issue is not in the risk activity itself, but in how a leader can take risks and display courage in order to lead effectively and influence others.

Courage can often be a series of small steps taken in the right direction at the right time regardless of the prevailing wisdom of those who remain at a standstill. Often risk is scary not because of the task that needs to be done but because of the uncertainty of the outcome.

There are risks and costs to a program of action, but they are far less than the long-range risks and costs of comfortable inaction.” John F. Kennedy

Smart leaders help make courageous commitments as conservatively as needed. A leader’s role is to move the team, not just take the risks themselves. A successful leader will focus on the small steps that will lead a group to the end goal.

  • Will you make sure expectations are in alignment through candid discussion with your team?
  • Will you fight against ambiguity within your team environment by not promoting secrecy or confusion?
  • Will you view encouragement as a vital way to empower and encourage your team members?

A leader rewards those who attempt even if they fail. Make a point to console your team members who become discouraged when their attempts fail. Enjoy their successes and bestow some positive publicity whenever possible. Share the times when your own risks paid off or when your own failures led to growth in other areas.

I think all great innovations are built on rejection.”
Sculptor Louise Nevelson

A leader ensures that all ideas are up for discussion. Strive to encourage disagreement, diversity and openness. Work to create an environment that fosters contribution and cooperation instead of competition and secrecy, an environment in which your team members feel free to share their talents.

All Risk Involves Movement: A Step, Jump, or Leap.

  • A step is moving forward incrementally, as you do when walking.
  • Jumps are a series of calculated moves designed to achieve a goal.
  • Leaps are the most risky, undertaken because of an underlying belief that you (and your team) will have sufficient momentum to reach your target.

When Risk Runs Relationships

The way a leader responds or reacts to normal natural conflict sets the tenor of events to come. Regardless of what the other person does, decide what you will do. This is the essential heartbeat of leadership. In Latin, it is called “locus” or the place of control deep within you. Know your locus-of-control and you will always have the choice to act as you need to act.

Leaders who work to elicit ideas from team members allow for people to feel what they want the most – involvement, affirmation, and ownership. Making change happen is a leader’s riskiest move. It is a test of whether you know and are known, whether you listened and are listened to, and whether your leadership will move or stagnate.

A ship in port is safe, but that’s not what ships are built for.”
Grace Murray Hopper, mathematician and computer pioneer

Hospice Deprescribing and Goals-of-Care Discussions

Shaida Talebreza, MD HMDC

Editor’s note: In the fall 2014 Quarterly Clinical Pearls Article “Goals-of-Care Discussions for Deprescribing,” Dr. Talebreza shares ways (and even a sample script) for healthcare providers to engage patients in decision making regarding medication deprescribing. The following is a tool, created by Dr. Talebreza, to help hospice professionals to determine the category of the hospice medication and to initiate a conversion with the patient and his or her family about the topic. Additionally, Dr. Talebreza has provided further information regarding recent CMS guidance. How have you approached this situation or what questions might you have? We welcome you to leave your comments below.

On March 10, 2014, CMS issued guidance to the hospice community and Medicare Part D Sponsors on Part D payment for drugs for beneficiaries enrolled in hospice. On July 18, 2014, CMS issued revised guidance .

Drugs Covered Under the Hospice Benefit

The hospice plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. As such, there may be some medications that were used prior to the hospice election that will continue as part of the hospice plan of care, and would be covered under the Medicare hospice benefit, if those drugs are necessary for the palliation and management of the terminal illness and related conditions (CMS, March 10, 2014).

We expect that Medicare hospice providers will continue to provide all of the medications that are reasonable and necessary for the palliation and management of a beneficiary’s terminal illness and related conditions (CMS, July 18, 2014).

Drugs That Are a Beneficiary Liability
There may be some drugs that were for the treatment of the terminal illness or related conditions prior to the hospice election that will be discontinued upon hospice election, as it has been determined by the hospice interdisciplinary group, after discussions with the hospice patient and family, that those medications may no longer be effective in the intended treatment, or may be causing additional negative symptoms in the individual. These medications would not be covered under the Medicare hospice benefit, as they would not be reasonable and necessary for the palliation of pain or symptom management. If a beneficiary still chooses to have these medications filled through his or her pharmacy, the costs of these medications would then become a beneficiary liability for payment and not covered by Part D. These medications would not be covered by Part D because their further coverage is prohibited under Medicare (CMS, July 18, 2014).

Similarly, if a beneficiary requests a drug for his or her terminal illness or related conditions that is not on the hospice formulary and the beneficiary refuses to try a formulary equivalent first; or the drug is determined by the hospice provider to be unreasonable or unnecessary for the palliation of pain or symptom management, the beneficiary may opt to assume financial responsibility for the drug. However, no payment for the drug will be available under Part D (CMS, July 18, 2014).

When a drug is determined by the hospice provider to be the beneficiary’s responsibility, Part D has no payment responsibility and payment coordination is not an issue (CMS, July 18, 2014).

Drugs Covered Under Part D for a Beneficiary Who Has Elected Hospice

For prescription drugs to be covered under Part D when the enrollee has elected hospice, the drug must be for treatment of a condition that is completely unrelated to the terminal illness or related conditions; in other words, the drug is unrelated to the terminal prognosis of the individual (CMS, March 10, 2014).

Influence Requires Empathy

By Kevin E. O’Connor, CSP

ACPE faculty member Kevin E. O’Connor, CSP, will present focused sessions on Relationship Building and Change Management at the AAHPM Leadership Forum: Ascend program, September 14-16, 2014. AAHPM Ascend is a new intensive program included in the AAHPM’s comprehensive new Leadership Forum.

“The greatest problem in communication is the assumption that it has taken place.” – George Bernard Shaw, playwright

When we wish to influence, we need to know others in a special and unique way. Empathy requires accurate listening, but it also requires an ability to communicate your understanding.

Summarize what you think you heard and ask if you have accurately understood. This shows the participant and the rest of your audience that you take the feedback seriously and that you are open to their viewpoint.

Influence Means Action
You must take action on what others are unwilling or too fearful to consider at any given time. Influence is about having a vision and a plan that is so elegantly simple that others will have a “why didn’t I think of that?” experience.

In presentations, that can simply mean helping your listeners figure out how they feel about a new idea or perspective. Take a poll. Share visions. Brainstorm solutions.

Afterwards, pay attention to their verbal and nonverbal feedback. See where there is room for improvement, where there is an opportunity to smooth out sections or make areas more clear.

Influence Through Simplicity
Everyone always has at least two major concerns as they enter meetings or presentations: “What is this about and what does it have to do with me?” Answer those questions, and you will increase your influence.

  • Steer clear of surprises.
  • Use less jargon. Don’t create confusion by using less than clear language.
  • Avoid acronyms. State the words until you know your audience understands what the acronym letters stand for.
  • Use smart analogies that make sense, not worn out clichés that no longer connect with the listener.

Finish Strong
When you conclude a presentation, you need to reach inside other people and encourage them to be innovative and to try new things: “what would happen if we did this?” Always remain open enough to change your mind to welcome new ideas.

Why Focus on Goals When Coaching?

by William “Marty” Martin, PsyD MA MPH MS CHES

ACPE faculty member William “Marty” Martin will present a focused session on Coaching and Mentoring at the AAHPM Leadership Forum: Ascend program, September 14-16, 2014. AAHPM Ascend is a new intensive program included in the AAHPM’s comprehensive new Leadership Forum.

“A dream is just a dream. A goal is a dream with a plan and a deadline.” – Harvey Mackey

You cannot coach without goals. And goals without follow-up often results in dreaming, hoping and wishing. Coaching and goals together move you closer to achieving results. What are the results of coaching in palliative care/hospice settings? There are three levels of results: (1) individual; (2) group/team; and (3) organization. At the individual level, if physicians and other providers are meeting and exceeding performance expectations, then results are likely to be achieved. At the group/team level, if members of the team feel psychologically safe, experience support from each other, hold each other accountable, and meet or exceed expectations, then results are likely to be achieved. At the organizational level, if individuals can offer feedback to others, either in a supervisor: subordinate or peer: peer relationships, then results are likely to be achieved.

How do you set goals when you coach? A useful tool for setting coaching goals is the SMART tool. SMART goals are Specific, Measurable, Attainable, Relevant, and Time-Bound. As a coach, it is not your job to set SMART goals but to engage in a coaching conversation to enable the coachee to develop his/her own SMART goals. As a coach, you may want to ask questions about how the SMART goals were set and if they are formulated in a way to set the coachee up for success or failure. Part of your role as a coach is to guide the coachee to experience success and to constructively learn from failure. Resilience is desirable outcome arising from constructively learning from failure.

In closing, when you are coaching a peer or a subordinate or even yourself, remember that if you don’t have any goals, then you are not coaching. And remember that goal setting is not a vague, aspirational process but a deliberate process captured by the pneumonic SMART. The benchmark of success in coaching is the achievement of specific results.

Highlights of the September Issue of the Journal of Pain and Symptom Management

Listed below are a few articles from the most recent issue of the journal:

Relationship Between Symptom Burden, Distress and Sense of Dignity in Terminally Ill Cancer Patients
Karin Oechsle, Marie Carlotta Wais, Sigrun Vehling, Carsten Bokemeyer, and Anja Mehnert

Nurse and Physician Barriers to Spiritual Care Provision at the End of Life
Michael J. Balboni, Adam Sullivan, Andrea C. Enzinger, Zachary D. Epstein-Peterson, Yolanda D. Tseng, Christine Mitchell, Joshua Niska, Angelika Zollfrank, Tyler J. VanderWeele, and Tracy A. Balboni

Symptom Clusters in Patients With Advanced Cancer: A Systematic Review of Observational Studies
Skye Tian Dong, Phyllis N. Butow, Daniel S.J. Costa, Melanie R. Lovell, and Meera Agar

To access the articles, you must subscribe to JPSM or be a member of the American Academy of Hospice and Palliative Medicine (AAHPM). For further information on the Academy, call 847.375.4712 or visit

Submitted by: David J. Casarett, MD, MA, Senior Associate Editor, JPSM

The Coleman Palliative Medicine Education Program

Recognizing the importance of palliative care service and the shortage of trained palliative care providers, the Coleman Foundation of Chicago awarded a grant to the Chicagoland Palliative Medicine Physicians’ Collective to train medical and interdisciplinary providers at hospitals across the Chicago area.

The Mission
Improve the quality of palliative care services at hospitals in the Chicagoland area

Improve patients’ and families’ access to palliative care services

Build a supportive network of palliative care providers across Chicagoland

Coleman Palliative Medicine Fellows
20 existing fellows will become junior mentors

25 physicians, advanced practice nurses, social workers & chaplains will be accepted into cohort 2, 2015-2017

Faculty and Mentors
Interdisciplinary mentors from medicine, nursing, chaplaincy, and social work

Expert clinicians, educators and researchers in palliative care representing 10 10 leading academic medical centers, community-based hospitals, health care systems and hospices in the Chicagoland area

The Fellowship
A 2-year training designed for health care professionals consisting of bi-annual workshops focused on skill-building, one-on-one mentoring, direct observation, e-learning. Fellowship mentoring centers on creating, implementing and evaluating a sustainable practice improvement project.

To learn more about the program and how to apply please click on the following link to the program website

Applications are due November 1, 2014.

Sean O’Mahony MB BCh BAO, MS
Section Director Palliative Medicine
Medical Director Inpatient Services Horizon Hospice and Palliative Care Organization
Associate Professor, Department of Internal Medicine, Rush Medical College
Associate Professor, Department of Community, Systems
and Mental Health Nursing, Rush University College of Nursing

Stacie K Levine MD, FAAHPM Associate Professor Co-Director Palliative Medicine Fellowship Director, Hospice and Palliative Medicine University of Chicago Medicine

Food and the Dying Patient

I’m at the Intensive Board Review course in Boston and in the middle of a whirlwind of learning. Dr. Joseph Shega’s lecture on Dementia and feeding tubes provided excellent clinical evidence to support my article in yesterday’s New York Times Well Blog post, Food and the Dying Patient

By Jessica Nutik Zitter, MD

Highlights of the August Issue of the Journal of Pain and Symptom Management

Listed below are a few articles from the most recent issue of the journal:

Highlights of the August issue include all the papers from the
Special Section on Studies to Understand Delirium In Palliative Settings (SUNDIPS)

To access the articles, you must subscribe to JPSM or be a member of the American Academy of Hospice and Palliative Medicine (AAHPM). For further information on the Academy, call 847.375.4712 or visit

Submitted by: David J. Casarett, MD, MA, Senior Associate Editor, JPSM