Innovations in End-of-Life Care
an international journal of leaders in end-of-life care

Introducing End-of-Life Care into the University of Cincinnati Internal Medicine Residency Program

An Interview with Eric J. Warm, MD

Introduction

In 1997 the American Board of Internal Medicine (ABIM) incorporated a new requirement to include knowledge and skills in end-of-life care into US Internal Medicine residency training.¹ Working in tandem with ABIM, David Weissman, MD, Charles von Gunten, MD, Bruce Ambuel, PhD, and Patricia Mullan, PhD, began the National Residency End-of-Life Physician Education Project (NRELEP) to help residency programs develop the necessary infrastructure to meet these new requirements, first with a pilot project in 1998. The project has been funded by The Robert Wood Johnson Foundation. The success of the pilot project in working with 30 residency programs from the Upper Midwest led to the continuation of this educational effort. Currently more than 200 residencies have participated, including programs in internal medicine, neurology, family medicine, and surgery.

Dr. Eric Warm, associate program director of the University of Cincinnati Internal Medicine Residency Program, participated in the initial pilot program in fall of 1998. Now, four years later, he describes how he and his colleagues got started, the results of their residency curricular change efforts, and how these efforts have evolved over time. Dr. Warm continues to shepherd these changes and now also serves as faculty for NRELEP. What follows are edited comments from an interview conducted by Associate Editor Anna L. Romer, EdD. [Citation: Warm E, Romer AL. Introducing end-of-life care into the University of Cincinnati Internal Medicine Residency Program: An interview with Eric Warm. Innovations in End-of-Life Care. 2002;4(5): www.edc.org/lastacts/]

Participation in the Pilot Program

How did you become involved in this project? Who made up the team from your residency program to attend the pilot workshop in 1998?

The information about this program came across the residency program director Gregory W. Rouan's desk, and I volunteered to go with Mark Thrun, the chief resident at the time, who has since moved on. I looked at the National Residency End-of-Life Physician Education Project and agreed we could do better at teaching residents about end-of-life care; so I went to the meeting. That's how I got started.

At that time I was about as junior as you can get, having just finished my year as chief resident two years prior to attending the workshop. I'm the only one of the pilot team who is still at the Internal Medicine Residency at the Division of Internal Medicine at the University of Cincinnati, and this effort has become a crusade for me.

What areas did you choose to focus on, and what was your role in promoting these changes in curriculum?

During the two-day residency curriculum workshop, the participants have to come up with action plans for what they are going to do when they get back to their residency programs. So, the chief and I sat down and developed some ideas. Once we got back we focused on five specific activities:

1. Inaugurated a mandatory hospice rotation that occurs in second year for all residents.
2. Created Fast Facts, a one-page semiweekly newsletter.⁶ Each one is devoted to one specific question in end-of-life care. These Fast Facts serve as a tool to raise awareness of these issues.
3. Implemented an advance directive module in the clinic as part of the ambulatory medical education conference series.
4. Initiated a writing exercise for residents: keeping a reflective journal of their experiences during residency.
5. Conducted a faculty development course, and included end-of-life care during grand rounds and noon conferences.

Since that initial time, we've gone on to create additional activities. We now integrate some end-of-life care segments within the orientation program for interns (first year residents) to signal the value and importance of this domain at the outset of the residency program.

I will elaborate on each of our efforts in turn, the barriers we encountered, and lessons I've gleaned from this experience.

The Hospice Rotation

Prior to this project, we didn't have a hospice rotation. I designed the hospice rotation for the residency program director. We found time for it, by carving a couple of days each week out of the ambulatory block. So, the residents in their second year now go to Hospice of Cincinnati two days a week during their month-long ambulatory care rotation.

Hospice of Cincinnati is a not-for-profit hospice, with both an inpatient unit and many home-based patients. On Wednesday afternoons, residents go for rounds with the hospice director. The next day, they are each paired with a nurse to go on home visits. The hospice has a high daily census, so there's no shortage of home visits.

Prior to the creation of this rotation, there was no hospice officially associated with our hospital. All hospices came to our institution, but none had an official contract at the time. Hospice of Cincinnati was in another system, so it was tricky. I had to break a rule in order to get our residents to that hospice, but I thought that it was the best hospice, and they were willing to work with our residents, so I persevered.

We started the hospice rotation on July 1, 1999. Although we have 105 residents across all years of the residency, at any one time only 20 to 30 people a year go through the Hospice Rotation, six or so at a time at different times of year. All second year residents are required to do the rotation, however.

Do the residents have authority or direct responsibility for patients in the hospice?

No, they are functioning mainly as observers. Fortunately for us, the hospice director graduated from of the University of Cincinnati Medical School many years ago. She's taken on this task of educating internal medicine residents about end-of-life care as part of her mission.

Has the hospice rotation evolved since you began it?

Yes, we've actually changed what we do a bit. I have found that if you begin something and you don't keep on top of it, things change. At first, I was aggressive about talking to all the residents on the hospice rotation about their experience, and then it seemed to be on autopilot. At the end of last year, I found out it wasn't working out as well, and that they weren't getting as good an experience. The residents found, for example, that they were getting less and less exposure to the hospice director, and were spending more time standing around waiting for things to happen. I discussed this with the hospice director, and we fixed the problem.

This year, starting in July, on the fourth Thursday of each month, I meet with the second-year residents who are just completing their hospice rotation. We meet at eight o'clock in the morning, and we break whenever we're done. We talk about experiences, reflect on what they saw, and tie it into what they did and have seen in their other experiences in the hospital wards. I ask them one question, "How did it go?" And then I ask them a second question, which I learned from David Weissman: "What was difficult for you?" Then I try to keep quiet, other than to guide the conversation from piece to piece, because they have so much to say.

I do give them a chapter of a popular press book at the start of the month, Dave Eggers' A Heartbreaking Work of Staggering Genius.⁷ and ask them to read a chapter of it. The book describes the author's experience when both his parents die unexpectedly within one month of each other. His mother dies of leukemia, his father dies of cancer. At the time the author is in his early twenties, and takes on the responsibility of caring for a much younger brother.

The chapter I ask them to read is about an episode in his mother's illness with leukemia. She has already made the decision not to go back to the hospital and then, she starts bleeding. The author describes this whole scene about whether his mother's going to go back to the hospital or not, and then she ends up back at the hospital. The reason I assign this chapter is that as doctors, we just see the "back in the hospital" part of the story. But the author gives the reader the 35 pages of back-story, about how his mom got there, which is so personal and evocative. I want the residents to wonder about the back-story for each of their patients, not just their own needs for sleep when a patient comes in at 2 in the morning.

Since we just started this session in July, I've only had two months experience with it so far. To be honest, it's been my favorite couple hours of the month.

Were there any other things you had to create to make the rotation work?

I created a syllabus. I'm now in my fourth edition of it. In the first version I took the best parts out of the Oxford Textbook of Palliative Medicine⁸, and some sections from the EPEC Trainer's Guide.⁹ It was a hodgepodge. I wrote a letter in which I explained to the residents why I thought the hospice rotation was important. Now I've toned the syllabus down a bit. The syllabus, which is a reference guide, now contains materials from EPEC and some poetry that I thought was good. I also include some Fast Facts that I thought were applicable to residents, such as Death Pronouncement in the Hospital, Do-Not-Resuscitate (DNR) Discussion, and How to Write a Condolence Letter. I put the Fast Facts in the front, because I know from experience that residents will need and use them. I don't expect them to read the whole binder, but I tell them what's in it and to keep it on their shelves as a reference.

Fast Facts and Concepts in End-of-Life Care

In retrospect, the element with the greatest impact was the Fast Facts newsletter. I had just gotten cable TV that year and the idea came from watching Headline News on CNN. As you probably know, they give the viewer the 40 words it takes to get the story out, and then at the bottom of the screen is a running strip of text with the same message, only in fewer words. It gave me the idea that people just want less, rather than more. The idea was that if I put a one-page newsletter in residents' and faculty mailboxes, they'd pull it out, look at it, and by the time they figured out they didn't want it, they'd have already read it. This was before e-mail really took off, so I was literally stuffing mailboxes. Unannounced, unwanted, I put each issue of Fast Facts in everyone's mailbox. Now I send it out via e-mail.

My goal was to make it short and to the point. Each Fast Fact addressed just one question, for example, "Do you know what an advance directive is?" Then, I'd answer it in less than one page, in big print.

Fast Facts took off like wildfire because it was so easy. Word got around the medical school, and soon different residency programs and health personnel across the medical center were requesting them. The assistant dean for medical education got a hold of it, and asked me to send it to everyone in my medical institution. I was asking some difficult questions, initially. And surprisingly, this one-page sheet was spawning these great discussions and responses.

Where would these discussions happen?

People would come up to me in the hallway, at morning report, on rounds. I became known as Mr. Death (Dr. Death was already taken by Dr. Kevorkian). But I'd just be walking in the hallway, and somebody would come up to me and say, "Oh, I got that Fast Fact. And let me just tell you, you're wrong on this issue," or "I'm so glad we're talking about that," or whatever. My favorite was this question about hope.¹⁰ Doctors are always afraid if we tell a patient something bad, we're going to take away hope. During my residency, not one word was said about that topic. And now these discussions have begun to make it legitimate.

What kind of feedback did you get from the residents?

Some of the early Fast Facts were on topics that were of immediate use for most residents, for example, DNR discussion, or how to pronounce someone. Those were big topics for the residents. They would call me and say, "I need to get a copy of that, please. Can you send it to me? I need it now because I have to do one of these things." Now that the whole Fast Facts library is on the Web, residents have access to them anytime, so I don't hear from them directly so much. I think the hospice rotation has really changed people, as well. Dying is not just a black box anymore. These Fast Facts have evolved since we began publishing them on the Web. Each one now has a little bit more information than it did originally.

Advance Directive Module

We created an advance directives module in our ambulatory medical education conference series, which takes place once a year. Residents have one half-hour of educational time every day before they go to clinic and see their outpatients. So we developed a four-week block during which they learn about advance directives. The first week, we read an article.¹¹. The second week, we read "Ten Myths about Advance Directives"¹² and we talk about it. The third week, we read about the SUPPORT trial¹³ and the fourth week, we actually fill out advance directives for ourselves. We tend to organize blocks in this way because residents don't always read for every session. By having multiple sessions on important topics, we ensure they are exposed at least a few times to each concept.

What Didn't Work: Writing

The one idea I had that didn't work was the writing. I thought it would be helpful for residents to keep a reflective journal. And I got zero, nothing. I didn't get a single thing back. Asking residents to write just doesn't work.

Do you think it is a question of time?

I think they don't write or reflect much in their daily lives. People don't sit and reflect. I think it's a rare person who keeps a journal anymore. So, when you ask people who are already busy and who don't see that activity—to reflect and write—as a priority, so they just don't do it.

Faculty Development

We implemented a one-day faculty development course, and asked David Weissman to lead it. Many faculty attended the seminar, some of whom I would have never expected. The discussion was rich, and many important end-of-life care issues were raised. Many of these people had been my teachers, and never before had I heard them discuss these topics with such openness and passion. The conference opened a few doors and allowed similar smaller conferences to be scheduled. However, since that time I have not worked so specifically on faculty development. I consider this relative neglect both a failure and an opportunity waiting to be taken.

The Impact of Fast Facts

Personally, coming up with this simple idea changed my life. Again, it was being at the right place at the right time. Everybody wants this information because it's the topic of the day and it's different. End-of-life questions feel more personal than, say, kidney problems.

At the end of the first pilot year, all the participants in the initial workshop got back together with David Weissman and the other faculty to report on what we'd done. David has been a champion of Fast Facts ever since, and now publishes them on EPERC (End-of-Life Physician Education Resource Center).¹⁴ He assigned a cadre of well-known writers to create additional Fast Facts that are now distributed and published in a variety of ways. The idea has grown and I am now only one of the many writers of them.

Cost

Good question. Initially, it was the paper costs for the Fast Facts. But the main costs were those associated with faculty time.

Do you have to pay the hospice to have the hospice rotation?

No, we don't. This particular hospice has an aggressive outreach program. They wanted to educate people. This collaboration is another example of being at the right place at the right time. It meets their needs.

Finances have gotten a bit tighter here. But I feel we have to keep thanking the hospice director and just tell her what a great job she's doing, because she's doing it for free. So, periodically, I ask my program director to send her some kudos. I called her up just a couple months ago and told her how much she's changed our residency program.

Champion

Are you the sole champion for these changes at your residency program?

I have some friends, let's put it that way. But in the medicine department, I'm pretty much "it" right now. However, there's a woman who just completed the faculty development program at Harvard,¹⁵ whose mother recently died. The death didn't go well and I believe this experience has changed her life and led her to become a hospice physician. I hope we can strike up a collaboration. I already collaborate with the family practitioners in the family medicine residency.

Was the fact that you were very junior, at the beginning, a problem for this initiative?

I've been here now at the University of Cincinnati since 1985, and I've been in the medical school since 1989. Everybody knows me. I know everybody. And I was chief resident here. When you're chief resident, the best part is that you have the hand of your boss always helping you, because you're acting as his mouthpiece. People got used to seeing me in a role of change-maker. Not necessarily my own change, but I used to be the guy who took orders from above and would go make change. So, being a junior physician wasn't actually a problem.

It sounds as though you actually had a lot of authority.

It wasn't exactly authority, but they were willing to give me the benefit of the doubt and a few minutes of their time. I did not try to butt my head up against the senior faculty who weren't going to change. My goal was to talk to the residents, who were on my side, and the faculty that I knew well, and say, "Look, I think this is something that's important." And start from the ground up.

Intern Orientation

Every residency has an orientation for interns every year. At the orientation, we tell the interns what we think they have to know to get through their internship year—for example, how to put in a central line, how to resuscitate people. This year, we decided that we should put some end-of-life care topics into orientation week to signal their importance. Actually, the end-of-life care portion of the orientation was a collaboration among medicine, surgery, neurology, and family medicine residencies.

We took one half-day out of all of our orientations and put the faculty and residents together. It's very unusual to conduct interdisciplinary education. Initially, it was just the family practitioners and our faculty. We presented four modules:

1. Do-Not-Resuscitate (DNR) issues
2. Hospice 101
3. Decision-Making Capacity
4. Breaking Bad News

Then the neurologists heard about what we were doing, and it fulfills their ACGME (Accreditation for Graduate Medical Education) requirements, too, so they joined. And then the surgeons joined the effort. We had 88 interns from all these disciplines, mixed up together. We divided them into groups of four, and every 45 minutes they'd move to a different module.

Content and Methods of the Modules

There were no lectures. I conducted the DNR module using role plays. Then, I had some prepared remarks, based on what they came up with.

So, you had them role play without having any information about how to do it right?

Exactly. David Weissman and his crew have a very nice module on how to diffuse the pain of a role play, because no resident wants to do role plays. I've learned from them to diffuse that resistance by addressing it.You say, "We're going to do a role play." Everybody groans. And then you acknowledge the groan and you say, "Why are you groaning? What is it about role plays that makes it difficult?" And then they say, "Well, it's not real." (The response is always the same.) I respond: "Well, putting that central line in the dummy wasn't real, but you did it anyway, so as to be ready for the real thing. Suturing the pig's foot isn't the same as suturing a person's foot, but you practice. It's the same thing with these words. Role plays aren't real, but they can serve as practice to make it easier the first time you find yourself in a situation facing a DNR order and it is real."

Second, you address the exposure people feel when they do role plays. You allow the intern who played the role of physician and who therefore took the greatest risk, to debrief first. You ask that person, "What was difficult for you?"

We break all the interns into groups of three with each person playing the roles of physician, patient, and observer, respectively. This way no one person is ever out in front of the whole group. I give them two scenarios in 45 minutes, so each person gets to play two different roles. Usually the discussion unfolds naturally, but I do have some summation slides. Through experience running these kinds of role plays, the key discussion points are invariably present on my slides.

For the Breaking Bad News module, we use a trigger tape from David Weissman. They get to watch someone else trying to break bad news, and the videotape has an example of a maladroit conversation and a more skilled one. The viewers have to observe and discuss what worked or didn't work in each scenario.

The Decision-Making Capacity module entails reading a short story, which presents a difficult ethical dilemma and so, by definition, has no clear answer. The residents need to try to come up with a response, based on whether or not the patient had decision-making capacity or not. Our goal is to identify and address some key ethical issues through this discussion.

The Hospice 101 module was probably the most didactic of all four. If we had to get rid of one module it probably would be Hospice 101 because I don't think that it applies to everyone. Certainly, the surgeons don't need it. Basically, the leader for this module discusses the nuts and bolts of hospice, such as who qualifies, who pays for the care, etc.

Feedback from Interns

We learned a few things from this experience. The good thing was to get all these programs together. We learned a few things about how not to do this, thanks to their feedback. Among the things we learned:

• Timing of Modules

  We offered these four modules the day before they were starting their residencies. Almost all the residents felt like that wasn't the most appropriate time in the orientation to cover this material. The next day they were on call, and they were anxious and needed time to rest. In response, we're going move the modules earlier into the orientation sequence. The interns get nervous as they get closer to the day they're going to start.

  There were a lot of people who said that they enjoyed the modules and that the content was valuable. Some interns reported that the content was unnecessary and ridiculous—that they didn't need this information. Those are the people I worry about most, of course. The physician who at this—or any—stage of his career feels he or she "knows it all" is a dangerous one. If you don't feel you need to learn something, you never will.

• Food

  Residents complained that we didn't give them enough food. We fed them lunch, and then the sessions started at 1:00 p.m., but we neglected to have cookies, or snacks later on in the afternoon. Many people actually commented on the absence of a snack. It turns out that food is an important motivator during residency.

• Equal Participation Across all Disciplines

  The third thing was that the moderators included two family practitioners, a neurologist, and me, representing internal medicine. That left a gap for the surgery residents. So next time we're going to get a surgeon to lead one of these modules, to legitimate it for the surgery residents.

Evaluation: Measuring the Impact of these Educational Efforts

For the intern orientation, we gave pre- and post-tests, on both end-of-life knowledge and attitudes. We have the feeling that these interns are going to differ by specialty, even though they hadn't done a single day of their respective residencies at that point, it's just that each group self-selects in terms of attitudes. The person who becomes a surgeon is a different person than the person that becomes a family practitioner.

We are also participating in David Weissman's study, which will track changes in knowledge and attitudes over time. These changes are measured through annual tests. The follow up has just begun, so we don't yet have any longitudinal results to report. We do know our data from the first year was terrible. Our residents scored 51 percent on a very simple knowledge test.

Evidence of Death and Dying Permeating Residency Life

I can see the effects of this new focus on end-of-life care across a number of areas.

First, questions about this domain occur in traditional educational formats, such as morning report. Now that I'm asked to do morning report once a month, the residents are saving up their difficult end-of-life issues for my session. There was no forum to discuss these cases previously. Ten to fifteen people attend. It's amazing how many questions there are. We have a hard core traditional medicine residency program, so open discussion of these dilemmas represents a change.

The second bit of evidence of a change in the climate regarding end-of-life care is that three of our residents in the last four years went into oncology fellowships. These residents said they are going to do hospice work. They haven't done it yet, but they said they will. We haven't had anyone in recent memory say that before, so, that is a big shift.

I think a subtle cultural change has taken place because we've been working in this area for a couple of years. This residency program isn't perfect, but it's getting better. End-of-life issues have begun to permeate the training, which is an improvement from where we began, with no public awareness and discussion of this topic.

My involvement with the residency program led to changes elsewhere at the University of Cincinnati medical school curriculum. These include participating in a task force to evaluate end-of-life care across the entire medical school curriculum, creating an end-of-life teaching module for the second-year clinical practice course, and inserting an end-of-life lecture and role-play into a third year clerkship.

Barriers and Strategies to Overcome Them

As you consider implementing curricular change, what are the main barriers you encountered and the strategies you used to overcome them?

• Interest

  The initial barrier was nobody wanted to hear about end-of-life care. That attitude is gone, pretty much, because of the ABIM requirements. Now, faculty members want to hear about these programmatic efforts because they help them check off requirements.

• Time

  The next barrier, as always, was finding time in a busy program. My approach has been: "Shoot first, ask questions later; make time." So, that's what we did.

  We worked to raise awareness. End-of-life issues infiltrated people's awareness through the Fast Facts, which caused a buzz, and that, in turn, helped address both of the first two barriers: generating interest and finding time.

• Absence of Legitimacy

  The third barrier, related to the first, was that this topic was not considered a legitimate or worthy topic of interest. In addition to the Fast Facts, one of the things we did early on was to conduct grand rounds on end-of-life care. We invited David Weissman down to give grand rounds, because he's an established expert. His example opened up my ability to give grand rounds, and then insert the topic into a clerkship at the medical school. So, you've got to transform this topic, which seems "soft," into an academic topic that is legitimized in the eyes of the hard core physician. You have to know your audience, and couch it in terms that mean something. Use data, show numbers that establish the problem as legitimate. These data create a felt need to study and address the problem. However, I do more than talk numbers; I bring home the topic by inviting listeners to connect it with their personal experience. The number one thing is to recognize one's own vulnerability. This point comes from my list of seven things we can each do today to improve end-of-life care. I present these in descending order during the lecture, and discuss each in depth.

At the end of my grand rounds, I tell a story of one of my own failures with a patient of mine. On the surface, the story doesn't sound like a personal failure, but I show how, when you really look at it, it was. I had planned the talk carefully, so I'd have seven minutes left after I finished my story. Then, I asked each member of the audience to turn to the person next to them and tell that person the story that had come to mind while I was telling my story. And every time I've done that, and I've done that eight times now, I can't shut them up.

The story I tell is the following:

I think this story works because every resident and attending has some version of that story and it provides a starting point for doing things differently. Telling this story embodies what I mean by making ourselves vulnerable. I model that stance and then give them permission to do the same when they talk with their neighbor about their own stories.

Sustaining New Practices

I think that most of these elements would remain. The program director of the internal medicine residency needs to have a hospice rotation because it's part of the ACGME, requirement. The hospice rotation isn't specifically required, but it fills so many of the requirements that if you have one, you can just check them off. We have a hospice rotation in which we have home visits, end-of-life care education, and we work in teams there, and all of these aspects fulfill ACGME requirements.

Key Lessons

1. Know your institution. As faculty for the National Residency End-of-Life Physician Education Project what I have found, meeting with people from all these residency programs is that every place is "differently the same." Does that make sense? That we all have a certain set of things that we have to deal with. A program director who is 55 years old would have implemented a more of a top-down approach. But that's not the way it was here. And so you have to approach it given the characteristics of your own setting.
2. Be persistent. For junior faculty, that's the most important thing.
3. Build tension for change. People have to feel a strong motivation to change. They need a reason to change. That's the classic model for change, but how it plays out is going to differ in each specific program.

References

1. Program Requirements for Residency Education in Internal Medicine. American Board of Internal Medicine, 1998.[Return to Featured Innovation]

2. Weissman DE. Improving end-of-life care: Internal medicine curriculum project: Project abstracts/ progress report. Journal of Palliative Medicine. 1999;2(3):331-344.[Return to Featured Innovation]

3. Weissman DE, Mullan PB, Ambuel B, von Gunten C. End-of-life curriculum reform: Outcomes and impact in a follow-up study of internal medicine residency programs. Journal of Palliative Medicine. 2002;5(4):497-506.[Return to Featured Innovation]

4. Mullan PB, Weissman DE, Ambuel B, von Gunten C. End-of-life care education in internal medicine residency programs: An interinstitutional study. Journal of Palliative Medicine. 2002;5(4):487-496. [Return to Featured Innovation]

5. Weissman DE, Mullan P, Ambuel B, von Gunten CF, Block S. End-of-life graduate education curriculum project: Project abstracts/progress report—year 3. Journal of Palliative Medicine. 2002;5(4):579-606.[Return to Featured Innovation]

6. Warm EJ. Improving EOL care—Internal medicine curriculum project. Journal of Palliative Medicine. 1999;2:339-340.[Return to Featured Innovation]

7. Eggers D. A Heartbreaking Work of Staggering Genius. New York: Vintage Books, 2000.[Return to Featured Innovation]

8. Doyle D, Hanks GWC, MacDonald N (eds.). Oxford Textbook of Palliative Medicine, 2nd ed. Oxford: Oxford University Press, 1998.[Return to Featured Innovation]

9. EPEC: Education for Physicians on End-of-Life Care, Trainer's Guide. An initiative of the American Medical Association's Institute for Ethics. The Robert Wood Johnson Foundation, 1999.[Return to Featured Innovation]

10. Warm EJ, Weissman D. Fast Fact and Concept #21; Hope and Truth Telling. www.eperc.mcw.edu [Return to Featured Innovation]

11. Aitkin PV. Advance care planning: Medical care at the end of life. American Family Physician. 1999;59(3):605-612.[Return to Featured Innovation]

12. Sabatino CP. Ten legal myths about advance medical directives. www.abanet.org/aging/myths.html [Return to Featured Innovation]

13. The SUPPORT principal investigators. A controlled trial to improve care for seriously ill hospitalized patients. Journal of the American Medical Association. 1995;274:1591-1598.[Return to Featured Innovation]

14. End-of-Life Physician Resource Center (EPERC) at www.eperc.mcw.edu now publishes more than 60 Fast Facts in addition to many other peer-reviewed print and video resources.[Return to Featured Innovation]

15. Program in Palliative Care Education and Practice: An Intensive Course for Nursing and Medical Educators. Harvard Medical School. www.hms.harvard.edu/cdi/pallcare/program.html [Return to Featured Innovation]