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In the setting of the COVID-19 pandemic as well as the recognition of systemic racism in our institutions, the symptom management, emotional/psychological support and advance care planning at the core of palliative care-once considered "an extra layer of support" -have been revealed as instrumental to individuals, families, communities, and countries facing the threat of the global pandemic. In this article, we outline the primary palliative care education efforts of one palliative care education center (The MERI Center at UCSF/Mt Zion campus) and detail the critical adjustments necessary and opportunities found in the COVID crisis.

Background: Although clinic-based palliative care (PC) services have spread in the United States, little is known about how they function, and no studies have examined clinics that predominantly serve safety net populations. Objectives: To describe the PC clinics operating in safety net institutions in California. Design: Survey completed by PC program leaders Setting/Subjects: PC programs in California, USA, safety net medical centers. Measurements: Descriptive statistics regarding staffing, clinic processes, patients served, and finances. Results: Twelve of 15 programs responded; 10 clinics that met inclusion criteria. All 10 programs use multiple disciplines to deliver care. Average full-time equivalent (FTE) used to staff an average of 2.75 half-day clinics per week includes 0.69 physician FTE, 0.51 nurse practitioner FTE, 1.37 nurse FTE, 0.79 social worker FTE, and 0.52 chaplain FTE. Clinic session schedules include an average of 1.88 new patient appointment slots (standard deviation [SD] = 0.44) and four follow-up appointment slots (SD = 1.95). The nine programs that reported on clinic volumes see 1081 patients annually combined, with an annual average of 120 (SD = 48.53) per program. Encounters per patient averaged 3.04 (SD = 1.59; eight programs reporting). All reported offering seven core PC services: pain/symptom management, comprehensive assessment, care coordination, advance care planning, PC plan of care, emotional support, and social service referrals. An average of 77.4% (SD = 26.81) of clinic financing came from the health systems. Conclusions: Our respondents report using an interdisciplinary team approach to deliver guideline-concordant specialty PC. More research is needed to understand the most effective and efficient staffing models for meeting the PC needs of the safety net population.

Hospital-based palliative care is becoming increasingly prevalent. There is growing evidence that it is having a positive impact on patients and their loved ones. In 2008, national data indicated that 58.5% of hospitals with 50 or more beds had a palliative care program. Data from a 2008 survey of California acute care hospitals showed that although 33% of sites had inpatient consultation services, one in five had been operational for only one year. As nascent palliative care programs grow, new issues arise and needs and plans change. Just as palliative care programs benefit from marketing and education plans, they also benefit from a plan to leverage external resources. Largely a missed opportunity, external resources such as organizations, networks, and experts can help palliative care service (PCS) leaders and team members gain information on everything from best practices to funding opportunities, while serving as sources for personal and professional support. The growing number of active PCSs and the increasing availability of support and expertise ensure that new programs no longer have to face challenges alone. Further, the steady increase in the number of new programs has created opportunities for those who are more experienced to serve as mentors for peers who are navigating the challenges of growing and sustaining a clinical service. The authors encourage both mentors and mentees to seek support from or provide support to others in the field. Leveraging the collective expertise and experiences in our field can ensure that palliative care continues to thrive and grow.

Background: Medical student end-of-life care training provides insight into the hidden curriculum and physician professional development., Description: Second-year medical students at a university medical center listen to a panel discussion of 4th-year students and residents describing their end-of-life care experiences during clerkships. This discussion is intended to provide "anticipatory guidance" to 2nd-year students about challenging situations they might encounter on the wards. The purpose of this study was to analyze the content of the panel discussions by 4th-year students and residents to better understand their views of the end-of-life care curriculum., Evaluation: We performed a qualitative content analysis of transcripts from 2 years of panel discussions. Participants' comments focused primarily on the complexity of the role of medical students in end-of-life care. Three major themes emerged in the sessions: defining professional identity, conflicting expectations, and limited medical experience., Conclusions: The role of medical students in end-of-life care can be complex, confusing, and contradictory. Emotional support and elucidating the hidden curriculum may assist students with the process of physician enculturation and end-of-life care education.

Background: Inpatient palliative care programs can improve care of patients with serious illness. We developed the California Hospital Initiative in Palliative Services (CHIPS) program to assist hospitals in establishing these programs. CHIPS included an introductory conference followed by 10 months of mentoring with telephone calls, e-mails, on-site consultation at the hospital, and a reunion conference., Methods: To evaluate CHIPS and the factors associated with establishing inpatient palliative care programs, we conducted a cross-sectional telephone survey of leaders from the 38 hospitals that participated in CHIPS. We assessed the number of inpatient palliative care consultation services established by hospitals that participated in CHIPS (success) and hospital characteristics associated with success., Results: Participants gave CHIPS high ratings. Six hospitals (16%) had a palliative care consultation service at enrollment in CHIPS and 19 hospitals (60%) established one after participation in CHIPS (P<.001). In bivariable comparisons, successful hospitals were more likely to have a hospitalist program (P = .003) or to be located in an urban setting (P = .03)., Conclusions: CHIPS seemed to help many hospitals establish inpatient palliative care programs. Hospitals with hospitalists and those in an urban setting were more likely to succeed in developing palliative care programs. Future studies should focus on the quantity and quality of care provided by these programs.

Background: Little is known about the use of palliative care for outpatients who continue to pursue treatment of their underlying disease or whether outpatient palliative medicine consultation teams improve clinical outcomes., Methods: We conducted a year-long controlled trial involving 50 intervention patients and 40 control patients in a general medicine outpatient clinic. Primary care physicians referred patients with advanced congestive heart failure, chronic obstructive pulmonary disease, or cancer who had a prognosis ranging from 1 to 5 years. In the intervention group, the primary care physicians received multiple palliative care team consultations, and patients received advance care planning, psychosocial support, and family caregiver training. Clinical and health care utilization outcomes were assessed at 6 and 12 months., Results: Groups were similar at baseline. Similar numbers of patients died during the study year (P =.63). After the intervention, intervention group patients had less dyspnea (P =.01) and anxiety (P =.05) and improved sleep quality (P =.05) and spiritual well-being (P =.007), but no change in pain (P =.41), depression (P =.28), quality of life (P =.43), or satisfaction with care (P =.26). Few patients received recommended analgesic or antidepressant medications. Intervention patients had decreased primary care (P =.03) and urgent care visits (P =.04) without an increase in emergency department visits, specialty clinic visits, hospitalizations, or number of days in the hospital. There were no differences in charges (P =.80)., Conclusions: Consultation by a palliative medicine team led to improved patient outcomes in dyspnea, anxiety, and spiritual well-being, but failed to improve pain or depression. Palliative care for seriously ill outpatients can be effective, but barriers to implementation must be explored.