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Objective: We examined whether conversations involving Black or Latino patients with advanced cancer differ in the presence or characteristics of prognosis communication., Methods: We audio-recorded initial consultations between 54 palliative care clinicians and 231 hospitalized people with advanced cancer. We coded for the presence and characteristics of prognosis communication. We examined whether the presence or characteristics of prognosis communication differed by patients' self-reported race/ethnicity., Results: In 231 consultations, 75.7% contained prognosis communication. Prognosis communication was less than half as likely to occur during conversations with Black or Latino patients (N = 48) compared to others. Among consultations in which prognosis was addressed, those involving Black or Latino patients were more than 8 times less likely to contain optimistically cued prognoses compared to others., Conclusion: Prognosis communication occurred less frequently for Black and Latino patients and included fewer optimistic cues than conversations with other patients. More work is needed to better understand these observed patterns of prognosis communication that vary by race and ethnicity., Practice Implications: Growing evidence supports prognosis communication being important for end-of-life decision-making and disproportionately rare among non-White populations. Therefore, our findings identify a potentially salient target for clinical interventions that are focused on ameliorating disparities in end-of-life care., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Objective: Clinicians frequently overestimate survival time among seriously ill patients, and this can result in medical treatment at end of life that does not reflect the patient's preferences. Little is known, however, about the sources of clinicians' optimistic bias in survival estimation. Related work in social networks and experimental psychology demonstrates that psychological states-such as optimism-can transfer from one person to another., Methods: We directly observed and audio recorded 189 initial inpatient palliative care consultations among hospitalized patients with advanced cancer. Patients self-reported their level of trait optimism and expectations for survival prognosis prior to the palliative care consultation, and the palliative care clinicians rated their expectations for the patient's survival time following the initial conversation with the patient. We followed patient mortality for 6 months., Results: Patient optimism was associated with clinician overestimation of their survival in a dose-response relationship. Clinicians were approximately three times as likely to overestimate the survival of patients endorsing both high trait optimism and optimistic ratings of their survival time compared with neither (OR: 2.95; 95% CI: 1.24-7.02). This association was not attenuated by adjustment for age, gender, race, ethnicity, education, income, cancer type, functional status, quality of life, or white blood cell count (OR adj : 3.45; 95% CI: 1.24-9.66)., Conclusion: Patients' optimism may have some influence over their clinicians' prognostic judgments., (© 2019 John Wiley & Sons, Ltd.)

Context: Clinicians frequently overestimate survival time in serious illness., Objective: The objective of this study was to understand the frequency of overestimation in palliative care (PC) and the relation with end-of-life (EOL) treatment., Methods: This is a multisite cohort study of 230 hospitalized patients with advanced cancer who consulted with PC between 2013 and 2016. We asked the consulting PC clinician to make their "best guess" about the patients' "most likely survival time, assuming that their illnesses are allowed to take their natural course" (<24 hours; 24 hours to less than two weeks; two weeks to less than three months; three months to less than six months; six months or longer). We followed patients for up to six month for mortality and EOL treatment utilization. Patients completed a brief interviewer-facilitated questionnaire at study enrollment., Results: Median survival was 37 days (interquartile range: 12 days, 97 days) and 186/230 (81%) died during the follow-up period. Forty-one percent of clinicians' predictions were accurate. Among inaccurate prognoses, 85% were overestimates. Among those who died, overestimates were substantially associated with less hospice use (OR adj : 0.40; 95% CI: 0.16-0.99) and later hospice enrollment (within 72 hours of death OR adj : 0.33; 95% CI: 0.15-0.74). PC clinicians were substantially more likely to overestimate survival for patients who identified as Black or Latino compared to others (OR adj : 3.89; 95% CI: 1.64-9.22). EOL treatment preferences did not explain either of these findings., Conclusion: Overestimation is common in PC, associated with lower hospice use and a potentially mutable source of racial/ethnic disparity in EOL care., (Copyright © 2018 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.)

Context: Maximizing value in palliative care requires continued development and standardization of communication quality indicators., Objectives: To describe the basic epidemiology of a newly adopted patient-centered communication quality indicator for hospitalized palliative care patients with advanced cancer., Methods: Cross-sectional analysis of 207 advanced cancer patients who received palliative care consultation at two medical centers in the U.S. Participants completed the Heard & Understood quality indicator immediately before and the day after the initial palliative care consultation: Over the past two days ["24 hours" for the post-consultation version], how much have you felt heard and understood by the doctors, nurses, and hospital staff?-completely/quite a bit/moderately/slightly/not at all. We categorized completely as indicating ideal quality., Results: Approximately one-third indicated ideal Heard & Understood quality before palliative care consultation. Age, financial security, emotional distress, preferences for comfort-longevity tradeoffs at the end of life, and prognosis expectations were associated with preconsultation quality. Among those with less-than-ideal quality at baseline, 56% rated feeling more Heard & Understood the day after palliative care consultation. The greatest prepost improvement was among people who had unformed end-of-life treatment preferences or who reported having no idea about their prognosis at baseline., Conclusion: Most patients felt incompletely heard and understood at the time of referral to palliative care consultation, and more than half of the patients improved after consultation. Feeling heard and understood is an important quality indicator sensitive to interventions to improve care and key variations in the patient experience., (Copyright © 2018 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.)

Background and Objectives: Building palliative care (PC) capacity in nursing homes (NH) is a national priority and essential to providing high quality care for residents with advanced illness. We report on NH staff experiences in developing and sustaining Palliative Care Teams (PCTeams) as part of a randomized clinical trial to "Improve Palliative Care through Teamwork" (IMPACTT)., Research Design and Methods: We conducted rapid ethnographic assessments of all NH (N = 14) in the intervention arm. Data included semistructured interviews with direct care and administrative staff (n = 41), field observations, and written materials. We used a phased approach to data analysis including open coding and comparative analyses within and across homes., Results: We found four key structural themes in our analysis including: administrative support, financial considerations, turnover and staffing, and competing priorities. The development and sustainability of the nascent PCTeams were constantly threatened by competing priorities and the key factor in their success was consistent and tangible administrative support., Discussion and Implications: While improving PC in NHs is a recognized priority, lack of stable infrastructure and unintended consequences of reimbursement policies created conditions which often thwarted the sustainability of the PCTeams.

Background: Prognostic uncertainty is common in advanced cancer and frequently addressed during palliative care consultation, yet we know little about its impact on quality of life (QOL)., Objective: We describe the prevalence and distribution of distress due to prognostic uncertainty among hospitalized patients with advanced cancer before palliative care consultation. We evaluate the association between this type of distress and overall QOL before and after palliative care consultation., Design: Observational cohort study., Setting & Participants: Hospitalized patients with advanced cancer who receive a palliative care consultation at two geographically distant academic medical centers., Measurements: At the time of enrollment, before palliative care consultation, we asked participants: "Over the past two days, how much have you been bothered by uncertainty about what to expect from the course of your illness?" (Not at all/Slightly/Moderately/Quite a Bit/Extremely). We defined responses of "Quite a bit" and "Extremely" to be indicative of substantial distress., Results: Two hundred thirty-six participants completed the baseline assessment. Seventy-seven percent reported being at least moderately bothered by prognostic uncertainty and half reported substantial distress. Compared with others, those who were distressed by prognostic uncertainty (118/236) reported poorer overall QOL before palliative care consultation (mean QOL 3.8 out of 10 vs. 5.3 out of 10, p = < 0.001) and greater improvement in QOL following consultation (Adjusted difference in mean QOL change = 1.1; 95% confidence interval = 0.2, 2.0)., Conclusions: Prognostic uncertainty is a prevalent source of distress among hospitalized patients with advanced cancer at the time of initial palliative care consultation. Distress from prognostic uncertainty is associated with lower levels of preconsultation QOL and with greater pre-post consultation improvement in the QOL.

Background: Deficits in end-of-life care in nursing homes (NHs) are reported, but the impact of palliative care teams (PCTeams) on resident outcomes remains largely untested., Objective: Test the impact of PCTeams on end-of-life outcomes., Research Design: Multicomponent strategy employing a randomized, 2-arm controlled trial with a difference-in-difference analysis, and a nonrandomized second control group to assess the intervention's placebo effect., Subjects: In all, 25 New York State NHs completed the trial (5830 decedent residents) and 609 NHs were in the nonrandomized group (119,486 decedents)., Measures: Four risk-adjusted outcome measures: place of death, number of hospitalizations, self-reported moderate-to-severe pain, and depressive symptoms. The Minimum Data Set, vital status files, staff surveys, and in-depth interviews were employed. For each outcome, a difference-in-difference model compared the pre-post intervention periods using logistic and Poisson regressions., Results: Overall, we found no statistically significant effect of the intervention. However, independent analysis of the interview data found that only 6 of the 14 treatment facilities had continuously working PCTeams throughout the study period. Decedents in homes with working teams had significant reductions in the odds of in-hospital death compared to the other treatment [odds ratio (OR), 0.400; P<0.001), control (OR, 0.482; P<0.05), and nonrandomized control NHs (0.581; P<0.01). Decedents in these NHs had reduced rates of depressive symptoms (OR, 0.191; P≤0.01), but not pain or hospitalizations., Conclusions: The intervention was not equally effective for all outcomes and facilities. As homes vary in their ability to adopt new care practices, and in their capacity to sustain them, reforms to create the environment in which effective palliative care can become broadly implemented are needed.

Background: The 2014 Institute of Medicine report recommended that healthcare providers caring for individuals with advanced illness have basic palliative care competencies in communication, inter-professional collaboration, and symptom management. Nursing homes, where one in three American decedents live and die, have fallen short of these competency goals. We implemented an intervention study to examine the efficacy of nursing home-based integrated palliative care teams in improving the quality of care processes and outcomes for residents at the end of life., Methods/design: This paper describes the design, rationale, and challenges of a two-arm randomized controlled trial of nursing home-based palliative care teams in 31 facilities. The impact of the intervention on residents' outcomes is measured with four risk-adjusted quality indicators: place of death (nursing home or hospital), number of hospitalizations, and self-reported pain and depression in the last 90-days of life. The effect of the intervention is also evaluated with regard to staff satisfaction and impact on care processes (e.g. palliative care competency, communication, coordination). Both secondary (e.g. the Minimum Data Set) and primary (e.g. staff surveys) data are employed to examine the effect of the intervention., Discussion: Several challenges in conducting a complex, nursing home-based intervention have been identified. While sustainability of the intervention without research funding is not clear, we surmise that without changes to the payment model that put palliative care services in this care setting on par with the more "skilled" care, it will not be reasonable to expect any widespread efforts to implement facility-based palliative care services., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Context: As endorsed by the palliative care "Measuring What Matters" initiative, capturing patients' direct assessment of their care is essential for ongoing quality reporting and improvement. Fostering an environment where seriously ill patients feel heard and understood is of crucial importance to modern health care., Objectives: To describe the development and performance of a self-report field measure for seriously ill patients to report how well they feel heard and understood in the hospital environment., Methods: As part of a larger ongoing cohort study of inpatient palliative care, we developed and administered the following point-of-care item: "Over the past two days, how much have you felt heard and understood by the doctors, nurses and hospital staff?" (completely, quite a bit, moderately, slightly, not at all). Participants completed the measure before and the day after palliative care consultation. For the postconsultation version, we changed the time frame from "past two days" to "today.", Results: One hundred sixty patients with advanced cancer completed the preconsultation assessment, and 87% of them completed the postconsultation version. Responses encompassed full use of the ordinal scale, did not exhibit ceiling or floor effects, and showed improvement from preassessment to postassessment. The item was quick to administer and easy for patients to complete., Conclusion: The "Heard & Understood" item is a promising self-report quality measure for the inpatient palliative care setting., (Copyright © 2016 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.)

Context: Palliative care (PC) promotes patient-centered outcomes, but the mechanisms underlying these effects remain poorly understood. Identifying, clarifying, and prioritizing patients' goals are conceptually fundamental to the process of patient-centeredness and are the main reasons for PC referral. However, very little is empirically known about the content or process of goal expression in the natural setting of PC., Objectives: To describe the frequency, types, and determinants of goal expression in PC consultations., Methods: This was a cross-sectional direct observational study of 72 audiorecorded PC consultations with hospitalized patients (and families) referred for PC goals of care clarification or end-of-life decision making. We coded digital audio files using reliable methods and linked conversation codes to clinical record and brief clinician interview data., Results: Goal expressions occurred frequently in PC consultations and addressed both length-of-life and quality-of-life domains. The presence of existential suffering in the conversation was associated with substantially more expressions and types of goals., Conclusion: Goal communication is common in PC decision-making settings and strongly influenced by existential suffering., (Copyright © 2015 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.)

Background: Understanding the characteristics of communication that foster patient-centered outcomes amid serious illness are essential for the science of palliative care. However, epidemiological cohort studies that directly observe clinical conversations can be challenging to conduct in the natural setting. We describe the successful enrollment, observation and data collection methods of the ongoing Palliative Care Communication Research Initiative (PCCRI)., Methods: The PCCRI is a multi-site cohort study of naturally occurring inpatient palliative care consultations. The 6-month cohort data includes directly observed and audio-recorded palliative care consultations (up to first 3 visits); patient/proxy/clinician self-report questionnaires both before and the day after consultation; post-consultation in-depth interviews; and medical/administrative records., Results: One hundred fourteen patients or their proxies enrolled in PCCRI during Enrollment Year One (of Three). Seventy percent of eligible patients/proxies were invited to hear about a communication research study (188/269); 60% of them ultimately enrolled in the PCCRI (114/188), resulting in a 42% sampling proportion (114/269 eligible). All PC clinicians at study sites were invited to participate; all 45 participated., Conclusions: Epidemiologic study of patient-family-clinician communication in palliative care settings is feasible and acceptable to patients, proxies and clinicians. We detail the successful PCCRI methods for enrollment, direct observation and data collection for this complex "field" environment.

Context: Lack of nursing home (NH)-specific palliative care practice guidelines has been identified as a barrier to improving palliative and end-of-life (EOL) quality of care., Objectives: The objectives of this study were to (1) assess which of the guidelines developed by the National Consensus Project, and the corresponding preferred care practices endorsed by the National Quality Forum, are important and feasible to implement in NHs; and (2) identify the operational standards for palliative care teams in NHs., Methods: Two-round mail Delphi study. Based on the existing literature, a set of 7 domains with associated 22 palliative practice guidelines was drafted. We invited 48 NH leaders, including clinicians, to review the importance (10-point Likert scale) and the feasibility (5-point Likert scale) of these guidelines. Participants were also asked about palliative care team composition rounding frequency., Results: The response rate to both rounds was 85%. With regard to importance, the mean rating for all guidelines was 8 or higher (ie, highly important), but there was variability in agreement with regard to 5 of the guidelines. The same 5 guidelines were also considered more difficult to implement (eg, costly, unrealistic). Overall, 17 palliative care guidelines were identified for use by NH palliative care teams. Five disciplines (social work, certified nurse assistant, nurse, physician, and nurse practitioner or physician assistant) were identified as comprising a core team and 3 were proposed as extended or ad hoc members., Conclusion: The palliative care guidelines and team standards identified in this study may be helpful in providing practical direction to NH administrators and staff looking to improve palliative care practice for their residents., (Copyright © 2015 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.)

Background: Seriously ill hospitalized patients and their loved ones are frequently faced with complex treatment decisions laden with expressions of emotional distress during palliative care (PC) consultations. Little is known about these emotional expressions or the compassionate responses providers make and how common these are in PC decision-making conversations., Objectives: To describe the types and frequency of emotional distress that patients and loved ones express and how providers respond to these emotions during PC decision-making consultations with seriously ill hospitalized patients., Methods: We used a quantitative descriptive approach to analyze 71 audio-recorded inpatient PC decision-making consultations for emotional distress and clinicians' responses to those emotions using reliable and established methods., Results: A total of 69% of conversations contained at least one expression of emotional distress. The per-conversation frequency of expressions of emotional distress ranged from 1 to 10. Anxiety/fear were the most frequently encountered emotions (48.4%) followed by sadness (35.5%) and anger/frustration (16.1%). More than half of the emotions related to the patient's feelings (53.6%) and 41.9% were related to the loved ones' own emotions. The majority of emotions were moderate in intensity (65.8%) followed by strong (20.7%) and mild (13.5%). Clinicians responded to a majority of emotions with a compassionate response (75.7%) followed by those with medical content (21.9%) and very few were ignored (1.3%)., Conclusions: Expressions of emotional distress are common during PC consultations and are usually met with compassionate responses by the clinician.

Background: Clinicians and patients find prognosis and end-of-life care discussions challenging. Misunderstanding one's prognosis can contribute to poor decision-making and end-of-life quality of life. A question prompt list (booklet of questions patients can ask clinicians) targeting these issues may help overcome communication barriers. None exists for end-of-life discussions outside the palliative care setting., Aim: To develop/pilot a question prompt list facilitating discussion/planning of end-of-life care for oncology patients with advanced cancer from Australia and the United States and to explore acceptability, perceived benefits/challenges of using the question prompt list, suggestions for improvements and the necessity of country-specific adaptations., Design: An expert panel developed a question prompt list targeting prognosis and end-of-life issues. Australian/US semi-structured interviews and one focus group elicited feedback about the question prompt list. Transcribed data were analysed using qualitative methods., Setting/participants: Thirty-four patients with advanced cancer (15 Australian/19 US) and 13 health professionals treating such patients (7 Australian/6 US) from two Australian and one US cancer centre participated., Results: Most endorsed the entire question prompt list, though a minority queried the utility/appropriateness of some questions. Analysis identified four global themes: (1) reinforcement of known benefits of question prompt lists, (2) appraisal of content and suggestions for further developments, (3) perceived benefits and challenges in using the question prompt list and (4) contrasts in Australian/US feedback. These contrasts necessitated distinct Australian/US final versions of the question prompt list., Conclusions: Participants endorsed the question prompt list as acceptable and useful. Feedback resulted in two distinct versions of the question prompt list, accommodating differences between Australian and US approaches to end-of-life discussions, highlighting the appropriateness of tailoring communication aides to individual populations.

Background: Prognosis conversations are complex phenomena of substantial importance to palliative care (PC), yet these remain poorly understood. This study empirically identifies and describes major types of prognosis conversations that occur in the natural setting of PC consultation., Methods: We audio-recorded and coded 71 inpatient "goals of care" PC consultations at a large academic medical center in the northeastern United States. We used quantitative Latent Class Analyses for identifying discrete prognosis conversation types and qualitative Dimensional Analyses for more fully describing the process and content of the latent classes., Results and Conclusions: We observed three discrete types of prognosis conversations, each placing different communication demands upon all participants for achieving goal-concordant care: Navigating Options & Goals (56% of consultations), Facilitating New Goals (23%) and Preparing for End-of-Life (21%). This study provides the first step for developing educational and clinical prognosis communication interventions that are tailored to common decision-making contexts facing seriously ill patients, their families, and PC clinicians.

Context: Palliative care (PC) consultations result in improved patient understanding of prognosis and better quality of life, yet the content and processes of prognosis communication during PC consultations remain unknown., Objectives: To describe prognosis communication during PC consultation with seriously ill hospitalized patients., Methods: We audio recorded 71 sequential inpatient PC consultations (initial visit) with seriously ill patients and their families who were referred for "goals of care" clarification or help with "end-of-life decision making." Conversations were coded using reliable methods and we then linked conversation codes to clinical record and clinician interview data., Results: Ninety-three percent of consultations contained prognosis communication. Participants communicated prognoses regarding quality of life more frequently than survival; focused prognosis estimates on the unique patient more frequently than on a general population; and framed prognosis using pessimistic cues more frequently than optimistic ones. Prognoses were more commonly spoken by PC clinicians than by patients/families. The following two factors demonstrated an association with the rate of prognostic communication and with the pessimistic framing of that information: whether the patient, family, or both participated in the conversation, and shorter expected survival (as estimated by the attending physician)., Conclusion: Prognoses are routinely communicated in PC consultations with hospitalized patients and their families. The rate and characteristics of prognosis communication differ based on the length of time the patient is expected to live., (Copyright © 2013 U.S. Cancer Pain Relief Committee. Published by Elsevier Inc. All rights reserved.)

Context: To provide effective palliative care (PC) to the geriatric population, an understanding of the reasons for consultation, main diagnoses related to referral, and symptom severity in chronic disease states is essential., Objectives: We compared the baseline characteristics, referral patterns, and symptom severity among older and younger patients referred for inpatient PC consultation., Methods: We conducted a retrospective review of 2382 inpatient PC consultations. We excluded "reconsultations" and patients under the age of 18. Patient characteristics (reason for consultation and diagnosis) and symptom severity were compared across three age groups: Younger, <65 years of age; Older, 65-84 years of age; and Oldest, 85 years of age and older. Multivariable logistic regression adjusted for the effects of gender, ethnicity, and diagnostic subset was performed., Results: Most patients referred for inpatient PC consultation were older than the age of 65. Oldest patients were consulted on earlier and more often for "end-of-life care." Oldest adults were less likely to report pain, anxiety, and nausea (adjusted odds ratios [AOR] of 0.25, 0.39, and 0.19, respectively) and more likely to report anorexia than Younger adults (AOR=1.66). There was no clear difference between age groups in reporting of dyspnea and depression., Conclusion: Older adults in need of PC appear to have symptom burdens and consultation referral patterns that are different from those of younger patients. Further research is needed to determine whether these symptom patterns are caused by psychosocial factors, whether these reflect true differences among age groups, and whether symptom measurement instruments should be tailored to patient age., (Copyright © 2011 U.S. Cancer Pain Relief Committee. Published by Elsevier Inc. All rights reserved.)

Patients facing serious or life-threatening illnesses account for a disproportionately large share of Medicaid spending. We examined 2004-07 data to determine the effect on hospital costs of palliative care team consultations for patients enrolled in Medicaid at four New York State hospitals. On average, patients who received palliative care incurred $6,900 less in hospital costs during a given admission than a matched group of patients who received usual care. These reductions included $4,098 in hospital costs per admission for patients discharged alive, and $7,563 for patients who died in the hospital. Consistent with the goals of a majority of patients and their families, palliative care recipients spent less time in intensive care, were less likely to die in intensive care units, and were more likely to receive hospice referrals than the matched usual care patients. We estimate that the reductions in Medicaid hospital spending in New York State could eventually range from $84 million to $252 million annually (assuming that 2 percent and 6 percent of Medicaid patients discharged from the hospital received palliative care, respectively), if every hospital with 150 or more beds had a fully operational palliative care consultation team.

Objective: To determine the pattern and characteristics of palliative care (PC) consultations in patients with stroke and compare them with the characteristics of nonstroke consultations., Methods: The palliative care program at Strong Memorial Hospital (SMH) was established in October 2001. SMH is a 765-bed academic medical center with approximately 38,000 discharges. For each consult from 2005 to 2007, we collected demographic, clinical, and service-related information. We explored similarities and differences in patients with different types of stroke, including patients with ischemic stroke, intracerebral hemorrhage, subarachnoid hemorrhage, and subdural hematoma. In addition, we compared these data to the nonstroke patients who had a palliative care consultation during the same time period., Results: Over the 3-year period from 2005 to 2007, there were a total of 101 consultations in patients with stroke (6.3% of all PC consultations). Of the 101 consultations, 31 were in patients with ischemic stroke, 26 in patients with intracerebral hemorrhage, 30 in patients with subarachnoid hemorrhage, and 14 in patients with subdural hematoma. Patients with stroke who had a PC consult were more functionally impaired, less likely to have capacity, more likely to die in the hospital, and to have fewer traditional symptom burdens than other common diagnoses seen on the PC consultation service. The most common trajectory to death was withdrawal of mechanical ventilation, but varied by type of stroke. Common treatments negotiated in these consultations included mechanical ventilation, artificial nutrition, tracheostomy, and less likely antibiobics, intravenous fluids, and various neurosurgical procedures., Conclusions: Patients with stroke are a common diagnosis seen on an inpatient palliative care consult service. Each stroke type represents patients with potentially distinct palliative care needs.

Introduction: Internal medicine programs are now required to integrate palliative care into teaching conferences, and palliative care content is already tested on the American Board of Internal Medicine examination. Previous research has focused on integration of palliative care into existing rotations and seminars, but none has studied a required inpatient palliative care rotation., Objective: We evaluate the impact of a required palliative care rotation for internal medicine residents in four domains: pain management, non-pain symptom management, communication/ethics, and terminal care., Methods: All second-year internal medicine residents (R2s) completed a required 2-week rotation in inpatient palliative care, and were asked to complete a previously validated palliative care examination immediately before and within 2 weeks after the rotation. During the same year, all interns (R1s) were also asked to complete this examination, as were third-year residents (R3s) who had completed the rotation one year earlier, to provide a basis for comparison. Participation in the examination was voluntary for all., Results: All interns (100%), and 71% and 87% of R2s and R3s, respectively, completed the examination. Mean examination scores improved by 12.4% between internship and start of the palliative care rotation, and by an additional 9.7% by the end of the rotation. Mean examination scores were consistent from the R2 to the R3 year. At all levels, residents scored well above the national average on the examination. Scores improved in all domains measured., Conclusions: Palliative care knowledge, as tested by objective examination, improves during internal medicine residency at our institution and specifically over the course of a required, 2-week palliative care rotation. Further study is warranted to determine the relative contributions to this improvement from the palliative care rotation itself, the institutional culture and/or Rochester residents' preexisting interest in the bio-psychosocial model.