Rotation: Elective

The fellow will spend one 4-week block on an activity of their choosing. Options include, but are not limited to, rotating with a subspecialty service at Texas Children's Hospital, spending additional time with a service outside Texas Children's (one included in core rotations or a novel opportunity), exploring a global palliative care experience. The rotation will be designed by the fellow and is subject to approval of the program director.

Rotation coordinator: Dr. Jill Ann Jarrell. Contact: jajarrell@texaschildrens.org. Phone: (832) 826-8046.

Clinical experience: Will vary depending on nature of elective.

Didactic experience: Will vary depending on nature of elective.

Daytime: Will vary depending on nature of the elective.

Call: No overnight weekday call and one weekend per month. Weekend calls include daytime rounding as well as overnight home call.

• Timely verbal feedback provided by faculty throughout rotation.
• Structured written evaluation of fellow using American Academy of Hospice and Palliative Medicine evaluation tools at end of rotation.
• Fellow provides feedback to program director about rotation at end of rotation.

Goals and objectives based on Pediatric Hospice and Palliative Medicine Competencies, version 2.0

*** The goals and objectives listed below will define the general expectations for the fellow while on elective, however the individualized nature of the elective will determine more specific goals and objectives as chosen by the fellow and subject to approval of the program director. ***

The fellow should demonstrate compassionate, appropriate, and effective care based on existing evidence base in pediatric palliative medicine and aimed at maximizing the well-being and quality of life for patients with chronic, complex, and/or life-threatening conditions and their families. The fellow should provide care in collaboration with other subspecialists and within an interdisciplinary team.

Objectives: At the completion of this rotation, the palliative care fellow will be able to:

• Obtain a comprehensive history and exam including:
  • Goals of care and advance care planning
  • Detailed symptom history
  • Psychosocial and spiritual history
  • Functional assessment
  • Quality of life assessment
  • Developmental age of the child
• Formulate a complete care plan utilizing evidence -based palliative medicine and including all members of an interdisciplinary team.
  • Use both pharmacologic and non-pharmacologic pain management interventions.
  • Assess and manage non-pain symptoms including nausea, vomiting, constipation, fatigue, depression, anxiety, dyspnea, delirium, and pruritus.
  • Understand and address the interplay between physical symptoms and psychosocial and spiritual distress.
  • Assess and manage psychosocial and spiritual distress in the patient and family.
• Demonstrate effective coordination of patient care, both from within an interdisciplinary palliative care team, with other palliative care providers including hospice teams, and in collaboration with colleagues outside of palliative care.
• Describe the way in which physicians outside of palliative care approach care for patients with palliative care needs.
• Identify key elements of care provided by other services that could be integrated into palliative care.
• Identify elements of palliative care that may be able to benefit providers from other services as they care for patients.

The fellow should demonstrate knowledge about established and evolving biomedical, clinical, population, and social-behavioral sciences relevant to the care of patients with life-threatening conditions and to their families, and relate this knowledge to the hospice and palliative care practice.

Objectives: At the completion of this rotation, the palliative care fellow will be able to:

• Describe the scope and practice of other key pediatric subspecialties as they relate to palliative care. Unique features of suffering for patients, families, and care providers in the care of children with life-threatening conditions.
  • Unique features in caring for pediatric patients in regard to physiology, vulnerabilities, development, and decision-making.
• Recognize and describe the management of pediatric life-threatening conditions including epidemiology, evaluation, prognosis, treatment, and patterns of progression.
  • Identify common diagnostic and treatment methods in the initial evaluation and ongoing management of pediatric life-threatening conditions.
  • Identify signs of advanced disease in pediatric life-threatening conditions.
• Apply knowledge gained from providers in other specialties to the care of palliative care patients.
  • Utilize knowledge from oncology, pulmonology, neonatology, and other fields to enhance ability to treat suffering in patients with a diverse range of conditions

The fellow should be able to investigate, evaluate, and continuously improve personal practices in caring for patients and families and appraise and assimilate scientific evidence relative to palliative care.

Objectives: At the completion of this rotation, the palliative care fellow will be able to:

• Utilize elective choice as a means to enhance education in areas of knowledge gaps or explore other areas of interest.
• Utilize self-evaluation and feedback from interdisciplinary team to appraise his/her performance and continually improve.
• Integrate knowledge gained and begins to serve as educator for trainees and other healthcare professionals.
• Identify knowledge gaps in the course of providing patient care and cultivate the habit of continuous inquiry to expand one’s knowledge base.
• Develop competencies as an educator.
  • Recognize the importance of assessing learning needs in initiating a teaching encounter.
  • Reflect on the benefits and drawbacks of alternative approaches to teaching and the role of different teaching techniques to address skills, knowledge, and attitudes.
  • Show respect toward learners and teachers, including children and families.
  • Demonstrate the ability to supervise clinical trainees (e.g., medical students, residents, other healthcare professionals) and effectively give constructive feedback.

The fellow should be able to demonstrate interpersonal and communication skills that result in effective relationship building, information exchange, emotional support, shared decision making, and collaboration with patients, patients’ families, and professional associates.

Objectives: At the completion of this rotation, the palliative care fellow will be able to:

• Initiate informed, relationship-centered dialogues about care.
  • Assess patient and family wishes regarding the amount of information they wish to receive and the extent to which they want and are able to participate in clinical decision making.
  • Assess the developmental level and cognitive understanding of the patient and appropriately include the patient in medical discussions and decision making.
  • Assess patients’ and family members’ decision-making capacity.
  • Assess patients’ and family members’ strengths and limitations of understanding and communication.
• Further develop professional communication skills through interactions with medical providers outside of palliative medicine.
• Demonstrate knowledge of the unique language of hospice and palliative medicine, effectively use this language in conversation, and begin to educate others in palliative medicine terminology.

The fellow should be able to demonstrate a commitment to carrying out professional responsibilities, awareness of his or her role in reducing suffering and enhancing quality of life, adherence to ethical principles, sensitivity to a diverse patient population, and appropriate self-reflection.

Objectives: At the completion of this rotation, the palliative care fellow will be able to:

• Demonstrate care that shows respectful attention to age/developmental stage, gender, sexual orientation, culture, religion/spirituality, disability, and family interactions.
• Demonstrate ability to conduct consultation with other healthcare providers in a professional manner.
• Demonstrate ability to balance the needs of patients, families, and team members with one’s own need for self-care.
• Recognize his/her own limits and ask for help when needed.
• Demonstrate accountability and ownership in interactions with patients, families, and colleagues.

The fellow should be able to demonstrate an awareness of and responsiveness to the larger context and system of healthcare, including hospice and other community-based services for patients and families, and the ability to effectively call on system resources to provide high-quality care.

Objectives: At the completion of this rotation, the palliative care fellow will be able to:

• Describe elements of the healthcare system relative to palliative care and constructs care plans that operate effectively within that system.
• Collaborate with all elements of the palliative care continuum, including hospitals, palliative care units, nursing homes, long-term care facilities, home and inpatient hospice, schools, and other community resources.
  • Utilize members of the interdisciplinary team to create smooth and efficient transitions across healthcare settings for patients and families.
  • Communicate with healthcare providers at the time of care transitions to clarify and coordinate the care plan across settings.
• Assess the value of care provided and advocate for care that is cost effective and represents best practices.