0830 h: I arrive at the palliative care office in the cancer institute, "borrow" whichever desk isn't in use, and get organized by looking at the schedule for the day and starting to look through those patients' charts.
0900 h: The palliative team (nurses, pharmacist, staff physician, and me) meet to run through the lists of new consults (usually two for the day), ward patients, outpatient follow-ups (mostly by telephone; some in-person), and new referrals to be triaged, and come up with a work plan for the day.
|palliative team meeting room|
1000 h: I walk upstairs to see the patient, taking a history, completing the palliative assessment forms, and performing a physical exam.
|the exam room with its shape-conforming mattress (which we're not supposed to tuck sheets under!)|
|lots of palliative assessment forms, which I fill out with the patient|
1130 h: The staff physician and I go back upstairs to discuss our plan with the patient. At this time we also discuss goals of care. We return downstairs to write prescriptions, which are faxed to the patient's pharmacy.
|at least I'm getting some exercise walking up and down these stairs all day!|
1205 h: I start dictating the new patient consult.
1300 h: I finish dictating (second only to geriatrics consults, palliative consults are the longest ever). I'm already running late for the second new patient so hurry upstairs to see them. As with the 10 am patient, I do a history, palliative assessment forms, and physical exam.
|more forms...this one is the ESAS-r (Edmonton Symptom Assessment System - revised), created locally and used widely!|
1430 h: Back upstairs to share said plan with the patient and discuss goals of care.
1500 h: Dictate...
1600 h: Finished dictating. Time to edit my dictations from yesterday, which always takes longer than expected given their novel-esque nature.
1700 h: Home
Days in palliative care are busier than I'd expected. Although we only see two new consults, they are complicated patients, each with multiple challenging issues. It takes some extra time to discuss things like psychosocial issues, hospice, goals of care, wills, and personal directives. Depending on the patient's stage of disease, the consult may proceed quite slowly, secondary to patient confusion, drowsiness, or mobility issues. In our once weekly multidisciplinary new patient consult clinics, one consult can take up to six hours, with the patient seen in turn by a nurse, dietician, occupational therapist, respiratory therapist, speech language pathologist, social worker, psychologist, spiritual care provider, pharmacist, resident, and staff physician.
Palliative care is an interesting and challenging area of medicine that I hadn't been much exposed to during medical school. My main goal for the rotation is to become more comfortable with prescribing pain medications -- and fortunately I'm getting more familiar every day with selecting and dosing opioids. I'm also getting to know anti-emetics and laxatives a whole lot better, which is sure to come in useful on every other rotation to come. I appreciate having just two consults a day, as it allows me to spend time being thorough with each one, so that I can get the most out of it in terms of learning (while hopefully also benefitting the patient!).
Have you done a palliative care rotation?
Have you come across any helpful palliative care resources?