Palliative Care Training for Geriatric Psychiatry Fellows: A National Survey Project

Abstract

Objectives:

Palliative care is an essential part of the standard of care for individuals with serious medical illnesses. Integration of palliative care and mental health is important for elderly patients with medical and psychiatric comorbidities. Geriatric psychiatrists are natural stewards of palliative care-mental health integration, however this is contingent on palliative care training. Currently, palliative care training in geriatric psychiatry fellowship programs is uncharacterized. We surveyed geriatric psychiatry fellowship program directors in the United States to assess current palliative care training practices.

Methods:

Web-based anonymous survey of geriatric psychiatry fellowship training directors

Results:

Forty-six percent (28/61) of program directors responded. Seventy one percent (20/28) of programs provide didactics on palliative care. Seventy-seven percent (20/26) of programs provide clinical experiences in palliative care. Sixty-three percent (15/24) have formalized interactions between geriatric psychiatry and palliative care fellows.

Conclusions:

Palliative care training for geriatric psychiatry fellows is robust but unstandardized. Operationalizing palliative care training for geriatric psychiatrists may improve mental health integration into serious illness care.

BACKGROUND

Palliative care is part of the standard of care for individuals with serious and life-limiting medical illness.¹ Palliative care focuses on relief from the physical and psychological symptoms as well as the distress associated with serious medical illnesses with the goal of improving patient and caregiver quality of life.¹ Through its development as a specialty, palliative care has expanded from a niche practice targeted towards people at the very end of life to a more expansive model serving individuals across a broader trajectory of serious medical illness. The presence of palliative care teams in hospitals increased by 178% between 2000 and 2016,¹ and approximately half of Medicare decedents nationally die in hospice care.²

Geriatric patients with serious medical problems have high rates of mental health comorbidities.³ These comorbidities have significant impacts on quality of life and medical care.³ Individuals with comorbid serious illness and mental health needs require an integrated approach to care.⁴ Mental health and serious illness comorbidity contributes to adverse serious illness care outcomes including increased rates of institutionalization at the end of life, decreased rates of advanced care planning, decreased access to specialty palliative care, and increased acute care utilization at the end of life.^5–9 However, palliative care and psychiatry largely operate within separate siloes with respect to training, reimbursement, and models of care delivery.¹⁰

Given the disparities noted above, elderly patients with significant medical and psychiatric co-morbidity are an exceptionally vulnerable cohort. This cohort is likely to grow as our population ages and as the burden of chronic illnesses continues to increase. The role of geriatric psychiatrists in palliative care provision exists on a spectrum from providing psychiatric consultation to specialty palliative care colleagues and their elderly, medically complex patients through provision of primary palliative care to geriatric patients with medical morbidities receiving psychiatric care who may not have access to specialty palliative care. Borrowing from models of geriatric psychiatry integration into primary care,¹¹ geriatric psychiatrists should be available to provide mental health consultation and follow-up to geriatric patients receiving palliative care. However, given significant gaps in both geriatric psychiatrists¹² and palliative care,¹³ geriatric psychiatrists should also be trained to deliver primary palliative care. There are several reasons why, despite geriatric mental health workforce shortages, it is important that geriatric psychiatrists develop fluency in primary palliative care skills.

Given the staggering need for geriatric mental health expertise, it is unrealistic to expect geriatric psychiatrists will be practicing in general palliative care settings. However, empowering geriatric psychiatrists to use existing knowledge and skills (in domains like serious illness communication, bereavement, and delirium management) to extend certain palliative care services (e.g., advance directives, appropriate hospice referral) to their own patients is an important step in addressing the disparities noted above for elderly patients with mental illness. While many elderly patients with mental illness will not be able to access palliative care services independently of their mental health treatment, including primary palliative care in the psychiatric treatment frame has the potential to improve serious illness care for this patient population. More generally, mental health and palliative care workforce shortages and the disparities noted above require novel, integrated models of mental health-palliative care delivery.¹⁰ Such models require clinical leaders with flexibility in deploying skills and knowledge from both palliative care and mental health in order to care for complex patients, teach clinicians across disciplines, and organize effective workflow. The cross-disciplinary needs of complex patients with serious illness and mental health comorbidities has been particularly emphasized by the COVID-19 pandemic, which has demanded that clinicians work across disciplinary siloes to adapt and deploy their skills in novel ways under novel conditions, including pushing mental health clinicians to deliver integrated mental health-palliative care.¹⁴

The ability to extend primary palliative care into the framework of mental health delivery is particularly germane in community-based, home, and long-term care settings in which geriatric psychiatrists have unique experience relative to most other medical and mental health providers. In addition, geriatric psychiatrists should have a leading role in palliative care of elderly individuals with neuropsychiatric disorders including dementias, particularly those receiving care in geriatric psychiatry settings such as inpatient units.¹⁵ While consultation-liaison psychiatrists can address many of these needs in acutely ill, hospitalized patients,¹⁶ geriatric psychiatrists are well situated to improve serious illness care for vulnerable elderly patients in care settings where such care may be lacking and with a number of geriatric neuropsychiatric syndromes for which both palliative care and psychiatric care are indicated.

Such leadership is contingent on training geriatric psychiatrists in palliative care. To meet the needs of vulnerable elderly patients with serious medical problems and mental health comorbidities, geriatric psychiatrists must understand systems of palliative care provision (hospice, palliative care, and so forth), work effectively with interdisciplinary palliative care teams, diagnose and manage psychiatric comorbidities among geriatric patients with serious medical illnesses, and develop skills in primary palliative care (advance care planning, serious illness communication, basic symptom management).

The necessity for geriatric psychiatrists to demonstrate proficiency in palliative care topics has been recognized in core curricula and core competency proposals;^17–19 current Accreditation Council for Graduate Medical Education (ACGME) “common program requirements” and milestones for geriatric psychiatry fellowships do not list palliative care as an area of training,²⁰ but a number of requirements set by the ACGME are palliative care-adjacent, such as mandates for pain management training and training in late-life development, which includes the end of life. In addition, proposed core competencies suggested by the American Association for Geriatric Psychiatry include a number of palliative care-related skills including “understanding and sensitivity to end-of-life care and issues regarding provision of care.”²¹ However, no data exists on the extent to which palliative care has been integrated into geriatric psychiatry fellowship training. To address this gap in knowledge, we conducted an anonymous survey of geriatric psychiatry fellowship program directors. Our aim was to characterize palliative care training of geriatric psychiatry fellows.

METHODS

We distributed an anonymous 16-question survey for geriatric psychiatry fellowship program directors, modified from a prior survey of CL psychiatry program directors,¹⁶ using the online survey tool Qualtrics. The original survey adhered, where possible, to the Association for Medical Education in Europe guidelines for development of educational research questionnaires.²² Questions included both multiple choice and free response format.

We surveyed fellowship program directors about program demographics (location, program size, academic versus community setting), availability of palliative care (fellowship program, clinical service, interaction with palliative care fellows) at the home institution, palliative care didactics (presence of formal didactics, topics covered, types of faculty lecturers), what percentage of the didactic curriculum is comprised of palliative care topics, clinical palliative care experiences (required versus elective, percentage of time devoted to these rotations), the most important palliative care skills in which geriatric psychiatry fellows should be trained, barriers to improving the palliative care training, and any additional aspects of the programs not addressed in the survey.

The survey was distributed in July 2020 to 61 program directors via the American Association of Geriatric Psychiatry’s fellowship program director email list-serv. Programs were identified using FREIDA, the American Medical Association’s online residency and fellowship program database. A reminder was sent to the list-serv two weeks following the initial email, and subsequently program directors were each emailed individually three weeks following the reminder. This anonymous survey was determined to be exempt from IRB review by the Columbia University Institutional Review Board.

Results were analyzed using descriptive statistics.

RESULTS

Survey responses were obtained from 28 of the 61 fellowship program directors (46%). Key results are reported in Table 1.

TABLE 1.

Palliative Care in Geriatric Psychiatry Training Programs

Institutional demographics:
Institution has a palliative care service	27/28	96%
Institution has a palliative care fellowship	24/27	89%
Formalized interactions between palliative care and geriatric psychiatry fellows	15/24	63%
Palliative care didactics:
Program provides didactics on palliative care topics	20/28	71%
Among those programs with palliative care didactics, proportion teaching:
Goals of care discussions and advance care planning	15/19	79%
Breaking bad news and other serious illness communication	12/19	63%
Bereavement/grief	12/19	63%
Psychosocial aspects of death and dying	12/19	63%
Systems issues in palliative care	11/19	58%
Assessment and communication of prognosis	10/19	53%
Ethics at the end of life	10/19	53%
Spiritual and existential aspects of serious illness	9/19	47%
Opiate pain management	7/19	37%
Other physical symptom management	5/19	26%
Non-opiate pain management	5/19	26%
Other	2/19	11%
Clinical palliative care experiences:
Program provides clinical palliative care experiences	20/26	77%
Core curriculum	15/20	75%
Elective only	5/20	25%
Among those programs with clinical palliative care experiences, proportion providing training in the following settings:
Inpatient palliative care consultation	15/19	79%
Psychiatric liaison to palliative care	5/19	26%
Outpatient palliative care clinic	4/19	21%
Psycho-oncology inpatient consultation	1/19	5%
Psycho-oncology outpatient clinic	1/19	5%
Other	3/19	16%

Program Demographics

Of the 28 programs, 96% (27/28) identified as academic, including one noting an additional community/rural component. One program identified as purely community-based. Most programs (19/28; 68%) have 2–4 fellows. Participating programs represented various regions of the United States including the Northeast (12/28; 43%), South (10/28; 36%), West (4/28; 14%) and Midwest (2/28; 7%).

Institutional Demographics

All but one program reported having a palliative care service (27/28; 96%). Eighty-nine percent of respondents (24/27) reported that their institution additionally has a palliative care fellowship program.

Palliative Care Didactics

Most programs (20/28; 71%) reported providing formal didactic instruction on palliative care topics. Palliative care teaching faculty included palliative care faculty (15/19; 79%), geriatric psychiatry faculty (10/19; 53%), geriatric medicine faculty (8/19; 42%), and CL psychiatry faculty (6/19; 32%). Among respondents with palliative care didactic content, 11/19 programs (58%) reported that palliative care topics make up approximately 1%–5% of their total didactic content, compared to seven programs (37%) reporting 6%–15%, and one program (5%) reporting 16%–25%.

The most commonly covered palliative care topics include goals of care discussions and advance care planning (15/19; 79%), breaking bad news and other serious illness communication (12/19; 63%), bereavement/grief (12/19; 63%), and psychosocial aspects of death and dying (12/19; 63%).

Clinical Palliative Care Experiences

Fifty-eight percent of respondents reported having formal clinical experiences in palliative care as part of the core rotations (15/26), 19% have these experiences as an elective option (5/26), and 23% reported not having clinical experiences in palliative care (6/26).

Nineteen of the 28 programs include a clinical palliative care experience. Of these, 15 (79%) have inpatient palliative care consultation experiences, five (26%) have a formal rotation as psychiatric liaison to palliative care, and five (26%) have outpatient palliative care clinic experiences. Of the 19 programs, 15 reported 1%–5% of fellows’ clinical time is devoted to palliative care rotations, and four reported 6%–15%.

Cross-Fellowship Interaction

Sixty-three percent of respondents (15/24) reported formalized interactions between geriatric psychiatry fellows and palliative care fellows, including shared didactics and joint palliative care rotations. A few qualitative comments suggest that some cross-fellowship interactions occur between geriatric psychiatry fellows and geriatric medicine fellows, rather than palliative care.

Key Palliative Care Topics

Program directors were asked to identify the most important palliative care topics. Of the 24 who responded, the most commonly identified topics were goals of care discussions and advance care planning (19/24; 79%), bereavement/grief (16/24; 67%), psychosocial aspects of death and dying (13/24; 54%), systems issues in palliative care (e.g., hospice referral, settings for end-of-life care, and payment models) (10/24; 42%), and breaking bad news/serious illness communication (8/24; 33%).

Barriers to Palliative Care Training

Twenty-one program directors identified barriers to palliative care education, with 76% identifying time (16/21); 19% (4/21) identifying lack of operationalized standards for curricula/rotations; 14% (3/21) identifying conflicting requirements for accreditation, interdisciplinary silos, and lack of qualified faculty; and 10% identifying lack of faculty interest (2/21).

DISCUSSION

The role of the geriatric psychiatrist vis-à-vis palliative care is evolving and there are significant opportunities for leadership given demographic changes and workforce challenges. Although geriatric patients with serious medical illnesses have high rates of medical comorbidity, specialist palliative care clinicians do not undergo required training in mental health provision.¹⁰ In addition, the current palliative care workforce is inadequate to meet the growing needs of patients nationally prompting an emphasis on dissemination of primary palliative care skills. In this study, we present the first data on palliative care training for geriatric psychiatry fellows drawn from a nationally representative sample of programs.

Our results show that most programs do provide didactics addressing palliative care topics, most commonly goals of care discussions and advance care planning, breaking bad news and other serious illness communication, bereavement and grief, and psychosocial aspects of death and dying. Seventy-seven percent of geriatric psychiatry programs in this sample report having clinical palliative care experiences, primarily inpatient palliative care consultation, and in the majority, these are part of the core curriculum. Of note, by far the most identified barrier to improving palliative care training was time. Encouragingly, these results suggest that geriatric psychiatrists are exposed to primary palliative care skills as well as to psychiatric aspects of palliative care. However, there may still be gaps in leadership training aimed at empowering new geriatric psychiatrists to comfortably work in palliative care settings. Evidence of these gaps include data showing a relative dearth of psychiatrists working in palliative care settings.¹⁰ Creation of national learning goals in palliative care for geriatric psychiatrists and representation of these goals in certification and accreditation criteria such as the ACGME Milestones may help guide programs to train new geriatric psychiatrists for leadership roles in improving serious illness care for geriatric patients with comorbid mental and medical illness.

We included data on the existence of palliative care services and fellowships at geriatric psychiatric fellowship training sites because the educational challenges and opportunities may differ based on existing palliative care service and training structures. Programs with palliative care services/fellowships may have greater siloing of roles, providing fewer opportunities for geriatric psychiatrists to provide primary palliative care. However, such programs may also benefit from the opportunity to foster cross-training and from specialist-level palliative care supervision of geriatric psychiatry fellows. Conversely, programs without co-existing palliative care programs may empower geriatric psychiatrists to utilize palliative care skills more extensively, but challenges in providing fellows with adequate training in these skills may be more pronounced.

Limitations of this study include the small sample size and 46% response rate. Our survey was composed largely of closed-ended questions, limiting our understanding of specific didactic and clinical content. Finally, our data do not include the trainee perspective, which may be incongruent with training director perspectives.

CONCLUSIONS

Elderly individuals with serious or life-limiting medical illnesses are a growing population who will need integrated mental health and serious illness/palliative care. Individuals with comorbid life-limiting illnesses and mental health needs experience disparate outcomes in end-of-life care including decreased specialist palliative care, less analgesia, loss of access to pre-existing mental health services, increased acute care utilization, and increased rates of institutionalization at the end-of-life.^5–8 Disparities in end-of-life care associated with mental health comorbidities are exacerbated by a lack of mental health-palliative care integration. By virtue of their knowledge about health systems, their expertise caring for elderly patients with medical and psychiatric comorbidity, and their communication skills, geriatric psychiatrists can be equipped to include primary palliative care into their clinical work with elderly patients with medical and psychiatric comorbidities and to create much-needed models of mental health-palliative care across community and healthcare settings. In particular, while such models do not yet exist, geriatric psychiatrists’ exposure to care models like PACE programs and the collaborative care model coupled with the palliative care training we discuss would give geriatric psychiatrists system-level skills and knowledge to approach the care of individuals with serious medical illness and mental health comorbidity. These roles are instrumental in addressing disparities for patients with mental health and palliative care needs. While our survey shows that geriatric psychiatrists already receive exposure to palliative care, operationalizing training around these common learning goals and ensuring those goals are reflected in certification and accreditation requirements may improve the care of vulnerable patients. Such training goals are consistent with ACGME mandates in the domains of patient care, medical knowledge, interpersonal and communication skills, and systems-based practice. Ultimately, with an investment in training and cross-disciplinary collaboration, geriatric psychiatrists are poised to lead the care of vulnerable elderly patients with serious medical illnesses and mental illnesses.

Highlights.

• What is the primary question addressed by this study?

  This is the first study to address training practices in palliative care among geriatric psychiatry fellowships nationally.

• What is the main finding of this study?

  While many geriatric psychiatry fellowships provide didactic and clinical exposure to palliative care, the content of such exposure is uneven and may not reflect topics identified as most important by training directors.

• What is the meaning of the finding?

  Operationalizing palliative care training for geriatric psychiatry fellows may help steward models of mental health-palliative care integration for elderly individuals with comorbid serious medical illness and mental illness.

DATA STATEMENT

The data has not been previously presented orally or by poster at scientific meetings