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Palliative and End of Life Care

Frailty Interactive Cases and A Facilitator’s Guide

:  
Date Posted: 
12/31/1969
Date Reviewed/Updated for Clinical Accuracy: 
12/31/1969
Product Information
Abstract: 

Introduction: Frailty is a diagnosable and treatable medical condition. It is a common syndrome in older adults, characterized by: physiological decline, marked vulnerability to adverse health outcomes, increased healthcare utilization, disability, high risk of falls, multiple comorbidities, and mortality. Our goal was to create a case-based educational resource in frailty for medical and other healthcare students.

Methods: A multidisciplinary team at the Miami VAHS, Geriatric Research Educational and Clinical Center, designed and implemented an 8-module educational resource on frailty: An Introduction and 7 cases covering screening, diagnosis, management, and comorbidities. This curriculum was used and evaluated by 4th-year medical students from the University of Miami Miller School of Medicine. Evaluation included a pre-/post-test and a curriculum evaluation with questions on content, learning objectives, value of the learning, and multimedia module usability. The Wilcoxon signed rank test was used with unilateral Monte Carlo significance to compare pre-/post-test performance, significant at p<.05.

Results: Fifty-one students completed 4 modules and the pre-/post-test from November 2020 to March 2021. Students’ post-test performance demonstrated significant improvement (p<.05) in knowledge of frailty. Fifty-five percent agreed the multimedia educational activity enhanced their knowledge of frailty and will include frailty assessment in their future practices. The combined “Good + Excellent” rating from evaluations of content linked to learning objectives ranged from 82.3-94.2%. Overall, written comments were positive regarding multimedia usability.

Conclusion: These case-based modules on frailty were highly rated and positively critiqued by students. Pre-/post-test evaluations demonstrated an increase in knowledge of frailty.

Keywords

Frailty, sarcopenia, comorbidities, multimedia, case-based learning

Educational objectives: 

There are twelve (12) learning objectives for the seven (7) cases; two learning objectives repeat for multiple cases. The number(s) in parentheses at the end of each learning objective below designates the cases in which the learning objective applies. All learning objectives start with the statement, “After viewing this module, learners will be able to describe.”

  1. Frailty can be diagnosed using accepted criteria and available tools (1)
  2. Frailty can be managed with literature-based interventions that include exercise nutritional support and optimized treatment of comorbid conditions (1)
  3. Frailty is a multifactorial illness with contributions from many domains of well-being: medical, psychological, social and functional (2 through 7)
  4. Frailty is often associated with a reduction in socialization that is often remediable with optimized care across all domains as well as care coordination (2)
  5. As is often the case in caring for patients with complex disease, it takes a team (2, 3, 6, 7)
  6. Frailty is often associated with cognitive deterioration that is often remediable with optimized care across all domains (3)
  7. Frailty is often associated with dependency and the need to recommend palliative care (4)
  8. Frailty is often associated with depression because both are common diseases (5)
  9. Depression can affect frailty by amplifying the symptoms of co-morbid conditions (5)
  10. Frailty coexisting with cognitive impairment need to be recognized early because of their mutual deleterious impact on function (6)
  11. The need to customized cancer care in frail patients based on comorbidities, function and prognosis (7)
  12. The importance of the social domain in care planning for patients with frailty and cancer (7)
Additional information/Special implementation requirements or guidelines: 

 

Facilitator’s Guide

Understanding Frailty: Screening, Diagnosis and Management

Authors

Lubna A. Nasr, MD

Department of Public Health, University of Miami Miller School of Medicine

Bruce W. Carter Miami VAMC, Miami, FL, USA

Raquel Aparicio-Ugarriza, PhD

ImFINE Research Group. Faculty of Physical Activity and Sport Science-INEF

Universidad Politécnica de Madrid, Madrid, Spain

Douglas Salguero, MD

Mount Sinai Medical Center, Miami, FL, USA.

Michael J. Mintzer, MD, AGSF

Director and Associate Director for Education & Evaluation

Miami Geriatric Research, Education and Clinical Center (GRECC), Miami, FL, USA

Acknowledgements

The authors would like to thank:

Rose van Zuilen, PhD, and Corinne B. Ferrari for their help in reviewing the modules and including this frailty training as a component of the MS4 geriatrics clerkship

 

Overview

Frailty is a term widely used in clinical medicine but often ill-defined. The primary purpose of these modules is to teach learners the definition, screening modalities and diagnostic methods for frailty. In addition, the secondary purpose to is display healthcare issues of older adults commonly associated with frailty. These include comorbid conditions, social disruptions, end-of-life care, etc.

This training is composed of eight PowerPoint narrated and animated presentations. PowerPoint was chosen because of its ubiquitous availability to virtually all learners. The introduction presents the basics of frailty definition, screening and diagnosis. The subsequent seven case-based modules ask students to apply their knowledge. We recommend that learners complete a minimum of four modules starting with the introduction and ending with Case 7; learners are free to choose two modules from cases 1 through 6 and are welcome to complete all these optional cases. Finally, case 7 is the most complicated and longest module; if a learner uses the fully narrated and animated features, it will run approximately 25-minutes. To meet individual needs, learners have the option to disable audio (narration and dialog) on some or all of the screens. (These PowerPoint-based modules do not provide the option of varying the speed of audio tracks as in some programs). Most students can complete the minimum of 4 modules in 60-75 minutes; all the modules can be completed in 2-2.5 hours. The list of module titles is included in Learning Objectives below.

All cases use a standardized template. Navigation instructions are included in the Introduction; all cases follow the same instructions. Learners must start with the Introduction followed by cases in numerical sequence; cases become more complex with progression. In evaluating this curriculum, we used: Introduction, followed by Case 1, Case 5 and Case 7. Students can return to the Introduction module at anytime to review terms and definitions.

Materials and Supplies

Access to a computer with Microsoft PowerPoint or other compatible software is required. Headphones or earbuds may be needed if learning is occurring in a congregate environment or because of learner preference. This training requires no other special instructions, materials or supplies. The PowerPoint presentations can be easily uploaded to the school’s learning management system for assignment to learners.

Learning Objectives

Learning objectives are included in each case. These objectives also act as a “preview” for the content within the animated and interactive modules. The introduction has no learning objectives because it is a “definition of terms” module for frailty, sarcopenia, and frailty screening, diagnosis and management. These topics are specifically addressed within the learning objectives of the cases. There are 12 unique learning objectives. Some of the learning objectives appear in more than one case. This is intentional. It allows learners to apply their learning to a new clinical circumstance or a new domain of care. The learning objectives follow the statement, “After viewing this module, learners will be able to describe:” and are listed here by case:

Case 1: Mild Frailty

  • Frailty can be diagnosed using accepted criteria and available tools
  • Frailty can be managed with literature-based interventions that include exercise, nutritional support and optimized treatment of comorbid conditions

Case 2: Moderate Frailty and Falling

  • Frailty is a multifactorial illness with contributions from many domains of well-being: medical, psychological, social and functional
  • Frailty is often associated with a reduction in socialization that is often remediable with optimized care across all domains as well as care coordination
  • As is often the case in caring for patients with complex disease, it takes a team

Case 3: Frailty and Cognitive Symptoms

  • Frailty is a multifactorial illness with contributions from many domains of well-being: medical, psychological, social and functional
  • Frailty is often associated with cognitive deterioration that is often remediable with optimized care across all domains
  • As is often the case in caring for patients with complex disease, it takes a team

Case 4: Severe Frailty, Dependency and Palliative Care

  • Frailty is a multifactorial illness with contributions from many domains of well-being: medical, psychological, social and functional
  • Frailty is often associated with dependency and the need to recommend palliative care

Case 5: Frailty and Depression

  • Frailty is a multifactorial illness with contributions from many domains of well-being: medical, psychological, social and functional
  • Frailty is often associated with depression because both are common diseases
  • Depression can affect frailty by amplifying the symptoms of co-morbid conditions

Case 6: Frailty and Major Neurocognitive Disorder

  • Frailty is a multifactorial illness with contributions from many domains of well-being: medical, psychological, social and functional
  • Frailty coexisting with cognitive impairment need to be recognized early because of their mutual deleterious impact on function
  • As is often the case in caring for patients with complex disease, it takes a team

Case 7: Frailty and Cancer

  • Frailty is a multifactorial illness with contributions from many domains of well-being: medical, psychological, social and functional
  • The need to customized cancer care in frail patients based on comorbidities, function and prognosis
  • The importance of the social domain in care planning for patients with frailty and cancer
  • As is often the case in caring for patients with complex disease, it takes a team

Evaluation

During this curriculum evaluation, we used identical pre- and post-tests, containing seven questions with twenty correct answers, to measure learning. This pre-/post-test is available upon request. All questions were effective in discriminating an increase in learning. Learner comments on content, presentation and usability of the modules were overwhelmingly positive.

Use of These Modules

These modules are free for use for all teachers, instructors and trainers. They can be used as produced and be incorporated into an existing curriculum, in part or in full. When these frailty modules are used or included in another curriculum, questions from the pre-/post-test may be adapted for assessments of students’ learning. As with all student assessments, these questions would likely require revision after several years of use. If adapted versions of this curriculum, or parts of this curriculum, are published, attribution to original authors must be included and these new materials must be equally accessible to teachers, instructors and trainers as are the original materials. These materials may not be used or adapted for commercial purposes. (See Creative Commons criteria: CC BY-NC-SA [Attribution-NonCommercial-ShareAlike]).

Date posted: 
Wed, 08/11/2021
Date Submitted or Reviewed/Updated for Clinical Accuracy: 
Wed, 06/09/2021
Contact Person/Corresponding Author:



Suggested Citation:
Frailty Interactive Cases and A Facilitator’s Guide. POGOe - Portal of Geriatrics Online Education; 2021 Available from: https://pogoe.org/taxonomy/term/4828

Palliative Care of a Patient with End-Stage Liver Disease: An Unfolding Case Study

:  
Date Posted: 
12/31/1969
Date Reviewed/Updated for Clinical Accuracy: 
12/31/1969
Other Learning Resource Type: 
Product Information
Estimated time to complete: 
2
Abstract: 

This case study was developed for use in academic coursework and as a standalone training for health care providers (MDs, ARNP, Pharmacists, Social Workers, Nurses). This unfolding case study about the management of an adult in the midst of a health crisis. This case is a composite of many actual cases seen in clinical practice. During the course of this case study, learners are presented with information as the providers learn of the patient’s emergent and ongoing health concerns – from his Emergency Department admission through the development of his palliative care plan. Learners are asked to make decisions and use their best judgment about how to care for this patient and family.

Educational objectives: 

By the end of this case study, the learner will be better able to:

  1. Understand the natural history and disease management of end stage liver disease (ESLD).
  2. Use evidence-based practice to collaboratively develop and refine goals of care for patients with chronic, progressive conditions.
  3. Work interprofessionally to ensure the best quality of care for the patient and family.
Date posted: 
Fri, 09/14/2018
Date Submitted or Reviewed/Updated for Clinical Accuracy: 
Wed, 08/15/2018
Contact Person/Corresponding Author:



Suggested Citation:
Palliative Care of a Patient with End-Stage Liver Disease: An Unfolding Case Study. POGOe - Portal of Geriatrics Online Education; 2018 Available from: https://pogoe.org/taxonomy/term/4828

Simulation Curriculum for Geriatric Medicine Fellows

:  
Date Posted: 
12/31/1969
Date Reviewed/Updated for Clinical Accuracy: 
12/31/1969
Product Information
Estimated time to complete: 
999
Abstract: 

This material consists of a suite of nine simulated clinical cases, divided into three separate sessions of three cases each, intended to be conducted in a simulation center with simulated patients.  Cases are designed to teach geriatric medicine fellows and other appropriate learners basic geriatric assessment skills (Session one), how to navigate difficult situations in long-term care (Session two), and high-level communication skills in palliative and end-of-life care (Session three).  Each case consists of a multi-page document outlining scripts for the learner as well as the roles (patient, family member, facility staff, etc) portrayed by actors, necessary props and supporting materials, and instructions for evaluating and debriefing the learner.  Also contained in each document are Entrustable Professional Activities (EPA), Curricular Milestones (CM), and Reporting Milestones (RM) relevant to the case.

Educational objectives: 

- Efficiently and effectively assess and manage common geriatric syndromes in a variety of clinical settings.

- Demonstrate the ability to navigate difficult communication scenarios in a long-term care environment, while providing leadership, mediating conflict between interdisciplinary team members and/or family members, and providing high quality care.

- Provide compassionsate, patient-centered care at the end of life, using high-level communication strategies.

Additional information/Special implementation requirements or guidelines: 

n/a

Publications from, presentations from, and/or citations to this product: 

None, though plans to present this at AGS/ADGAP in 2019.

Date posted: 
Mon, 11/12/2018
Date Submitted or Reviewed/Updated for Clinical Accuracy: 
Wed, 08/08/2018
Contact Person/Corresponding Author:



Suggested Citation:
Simulation Curriculum for Geriatric Medicine Fellows. POGOe - Portal of Geriatrics Online Education; 2018 Available from: https://pogoe.org/taxonomy/term/4828

Advance Care Planning

:  
Date Posted: 
12/31/1969
Date Reviewed/Updated for Clinical Accuracy: 
12/31/1969
Product Information
Estimated time to complete: 
2
Abstract: 

The Advance Care Planning Module uses a team approach to reduce errors and improve the quality of health care for older adults. This interdisciplinary formative assessment tool for Elder Safety can be utilized by fourth-year medical students, residents in training and practicing physicians. Learners will take a pre-test, review learning objectives, exemplar and video demonstrations, have access to reference materials and links to websites for Advance Care Planning. Content experts share their professional experience on the sensitive topic of addressing patient goals of care in preparation for death and dying.  Information on Advance Directives, legal considerations, clinician resources, cultural and gender differences, patient competency and capacity concerns are presented in a straight forward way to aid the medical professional in their ability to facilitate end-of-life care.  

Educational objectives: 

1. Healthcare professionals working with the 65 years and older population will develop knowledge and skills needed to formulate a health policy and educate patients about an Advance Care Plan.

2. Healthcare professionals working with the 65 year and older population will gain an advanced understanding of the options available to patients when planning end-of-life care.

Additional information/Special implementation requirements or guidelines: 

To access the material, go to the Learning Center at ilearn.nbome.org to access the Elder Safety Modules:

  • Select your learning activity (Advance Care Plan) and add it to your cart.
  • In the cart, click Proceed to Checkout. This will prompt you to either create a new account or login to your existing one.
  • Create your free account by entering the required information.
  • Once completed you will be directed back to the catalog to complete your course registration.
  • There is No Charge for viewing the Advance Care Plan Module.
Publications from, presentations from, and/or citations to this product: 

Presentation:

Marquez-Hall, S., Horber, D. (2017) Web-based formative assessment: An innovative way to assess and improve physician/patient care using an interprofessional team approach. Joint presentation with the National Board of Osteopathic Medical Examiners at the American Association of Osteopathic Medicine and Association of Osteopathic Directors and Medical Educators Annual Conference, Baltimore, MD

Date posted: 
Fri, 01/12/2018
Product Viewing Instructions: 
See Additional information/Special implementation requirements or guidelines under the Additional Details Section.
Contact Person/Corresponding Author:



Suggested Citation:
Advance Care Planning. POGOe - Portal of Geriatrics Online Education; 2018 Available from: https://pogoe.org/taxonomy/term/4828

Establishing goals of care- Standardized caregiver interview

:  
Date Posted: 
12/31/1969
Date Reviewed/Updated for Clinical Accuracy: 
12/31/1969
Other Learning Resource Type: 
Product Information
Estimated time to complete: 
1
Abstract: 

This Observed Standardized Caregiver (SCG) interview is designed to be used with geriatric fellows. The goal is to assess the fellow's competence in establishing goals of care with patient’s families in the ambulatory setting. 

Educational objectives: 

The case is designed to evaluate geriatric fellow’s ability to elicit the following core competencies in geriatrics assessment during a Standardized Patient Interview:
1. Establish that the caregiver is the appropriate health care designee
2. Introduce the need to have a discussion about overall goals of care
3. Establish what would be an acceptable quality of life for the patient
4. Assist the family with completing a written health care directive ( for this exercise a Practitioner Order of Life Sustaining Treatment  form - POLST )
 

Additional information/Special implementation requirements or guidelines: 


This exercise can be integrated into an ongoing geriatrics curriculum for geriatric fellows.
• An overview of the educational goals and patient characteristics is discussed with the fellow(s) prior to the session (15 minutes)
• Training of SCG (30 minutes)
• The fellow(s) are videotaped performing a caregiver interview (30 minutes)
• The fellow(s)complete a self-assessment tool (3 minutes)
• The SCG completes a fellow(s) assessment tool (3 minutes)
• The videotape is reviewed by the faculty with a standardized assessment tool (20 minutes)
• A group session to provide formative feedback is conducted with geriatrics faculty
 

Date posted: 
Thu, 11/16/2017
Date Submitted or Reviewed/Updated for Clinical Accuracy: 
Wed, 11/01/2017
Contact Person/Corresponding Author:



Suggested Citation:
Establishing goals of care- Standardized caregiver interview. POGOe - Portal of Geriatrics Online Education; 2017 Available from: https://pogoe.org/taxonomy/term/4828

Advance Directives

:  
Date Posted: 
12/31/1969
Date Reviewed/Updated for Clinical Accuracy: 
12/31/1969
Product Information
Estimated time to complete: 
1
Abstract: 

Advance Care Planning (ACP) is more than documenting life-sustaining treatment choices or identifying a surrogate decision-maker; it is a comprehensive, continuing communication and ‘shared decision-making’ process between the patient, family, and medical providers designed to document patient values and goals for treatment.

This interactive self- learning module is designed for undergraduate medical students with the goal of introducing learners to ACP while building their confidence in facilitating difficult conversations with patients. At the beginning of the module, we provide background on ACP including the challenges and benefits associated with the process. We showcase an elderly couple discussing how important it is to have advance directives in place. The second portion of the module reviews the common forms that are used to document advance directives and two patient case scenarios where the students can interact and reflect on the acquired content.

Educational objectives: 
  • Recognize the relevance in conducting and documenting advance directive discussions with patients.
  • List commonly used advance directives documents.
  • Develop the skills necessary to engage patients in a discussion about advance directives through the use of realistic patient case scenarios.
     
Date posted: 
Wed, 07/19/2017
Date Submitted or Reviewed/Updated for Clinical Accuracy: 
Sun, 07/19/2020
Product Viewing Instructions: 
Interactive self learning module
Contact Person/Corresponding Author:



Suggested Citation:
Advance Directives. POGOe - Portal of Geriatrics Online Education; 2017 Available from: https://pogoe.org/taxonomy/term/4828

Goals of Care/Medication Management Clinical Evaluation Exercise (Mini-CEX)

:  
Date Posted: 
12/31/1969
Date Reviewed/Updated for Clinical Accuracy: 
12/31/1969
Product Information
Abstract: 

This goals of care and/or medication management Clinical Evaluation Exercise (Mini-CEX) is designed to use with a learner during a patient encounter. The teacher observes the learner with a patient discussing goals of care and/or medication managment and completes the form. The teacher then reviews the form with the learner and provides feedback of what skills were observed, partially observed, not observed, not applicable and comments about the encounter.

Educational objectives: 

Learners who are administered this Goals of Care/Medication Management Mini-CEX will:
1)be observed discussing goals of care and medication management with their patients and families.
2)receive feedback about their communication skills with patients and families.
3)obtain record of their goals of care and/or medication managment assessment skills using a Mini-CEX.

Date posted: 
Mon, 01/23/2017
Date Submitted or Reviewed/Updated for Clinical Accuracy: 
Mon, 01/23/2017
Contact Person/Corresponding Author:



Suggested Citation:
Goals of Care/Medication Management Clinical Evaluation Exercise (Mini-CEX). POGOe - Portal of Geriatrics Online Education; 2017 Available from: https://pogoe.org/taxonomy/term/4828

Advance Care Planning and POLST Conversation Guide

:  
Date Posted: 
12/31/1969
Date Reviewed/Updated for Clinical Accuracy: 
12/31/1969
Product Information
Estimated time to complete: 
3
Abstract: 

This is an educational product to teach health care providers how to conduct goals of care conversations with patients and caregivers

Educational objectives: 

1. Recognize and respond to emotional cues during challening conversations  2. Demonstrate how to elicit patient perception of illness and goals of care 3. make a recommendation about code status based on patient's goals 4. Provided a basic description of CPR avoiding medical jardon 5. Discuss possible outcomes of CPR including survival percentages and possible risks.

 

Date posted: 
Mon, 10/17/2016
Date Submitted or Reviewed/Updated for Clinical Accuracy: 
Mon, 10/17/2016
Contact Person/Corresponding Author:



Suggested Citation:
Advance Care Planning and POLST Conversation Guide. POGOe - Portal of Geriatrics Online Education; 2016 Available from: https://pogoe.org/taxonomy/term/4828

Interdisciplinary Health Profession Module Videos

:  
Date Posted: 
12/31/1969
Date Reviewed/Updated for Clinical Accuracy: 
12/31/1969
Product Information
Estimated time to complete: 
1
Abstract: 

Care teams often don't know how to effectively and efficiently collaborate when addressing a patient’s health. Depending on a patient’s needs, team leadership can shift at any given moment from one person to another. Because of this constant jockeying and adaptation, educating learners about their own interprofessional relationships is becoming incredibly important. These videos and the corresponding text supplements provide a context for interprofessional team members to discover more about what it takes to become a member of another profession. This knowledge, combined with their own experiences and clinical practice, will assist in preparing learners for the next-generation of team-based healthcare.

Educational objectives: 

After watching these short 2-3 minute videos, interprofessional teams will be able to contextualize their own relationship within the group dynamic, understand the educational requirements that go into other disciplines, and formulate an effective team-based learning approach for future activities.

Date posted: 
Tue, 09/27/2016
Date Submitted or Reviewed/Updated for Clinical Accuracy: 
Tue, 09/27/2016
Contact Person/Corresponding Author:



Suggested Citation:
Interdisciplinary Health Profession Module Videos. POGOe - Portal of Geriatrics Online Education; 2016 Available from: https://pogoe.org/taxonomy/term/4828

The Geriatric Experience Multimedia Menu for Residents and Medical Students on Geriatrics Rotation

:  
Date Posted: 
12/31/1969
Date Reviewed/Updated for Clinical Accuracy: 
12/31/1969
Product Information
Estimated time to complete: 
3
Abstract: 

This multimedia menu was created to add variety to a geriatrics rotation for third- and fourth-year medical students and family medicine residents while exposing learners to different aspects of the social and ethical issues integral to the care for older adults. The menu includes multiple books, movies, online videos and podcasts that learners may choose from during an assigned half-day of the rotation. Afterward, learners complete a written, personal reflection that is submitted to the course director. Reflective ability is an important skill for practicing physicians that is rarely taught in a formal curriculum. This simple menu broadens the breadth of the geriatric rotation and creates an opportunity to practice reflection. 

Educational objectives: 

After completing this experience, learners will:

1. Critically reflect on clinical experiences through the lens of multimedia portrayals of issues related to older adults. 

2. Discuss ethical issues related to the care of older adults. 

3. Describe new insights from a variety of media types and apply these insights to future practice. 

Date posted: 
Wed, 10/05/2016
Date Submitted or Reviewed/Updated for Clinical Accuracy: 
Wed, 10/05/2016
Contact Person/Corresponding Author:



Suggested Citation:
The Geriatric Experience Multimedia Menu for Residents and Medical Students on Geriatrics Rotation. POGOe - Portal of Geriatrics Online Education; 2016 Available from: https://pogoe.org/taxonomy/term/4828

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