- Inpatient Consults in the ICU and hospital floors (approximately 6 months)
- Home Hospice (1.5 months for MD/DO fellows and 0.75-1 month for APRN fellows with the Visiting Nurses of NH and VT
- Inpatient Hospice Unit (2.5 months at the Jack Byrne Center for Palliative & Hospice Care)
- Long-term Care (2 weeks at Kendal at Hanover and 2 weeks with our DH Geriatrics team at local Skilled Nursing Facilities)
- Spirituality (0.5 month)
- Pain Clinic (0.25 months)
- Pediatric Complex Care Team at the Children’s Hospital at Dartmouth (CHaD) (0.5 months) – MD/DO fellows ONLY unless pediatrics is within APRN’s scope of practice
- Advanced Heart Failure Team (0.5 months; required for APRN fellows and available as an elective for MD/DO fellows)
- White River Junction Veterans Affairs Hospital (0.5 months) – MD/DO fellows only at this time due to credentialing limitations
- Hematology/Oncology Clinic at the Norris Cotton Cancer Center (0.5 months; required for APRN fellows and available as an elective for MD/DO fellows)
- CME/Vacation (one week/three weeks)
The consult service sees patients in various inpatient settings at Dartmouth-Hitchcock Medical Center (DHMC) including medical, oncology, cardiology, pediatric, surgical floor and critical care units. Daily Inter-Disciplinary Team (IDT) meetings are held with:
- Between one and six learners on rotation
- Creative arts
- Healing arts
- Licensed Nursing Assistants (LNAs)
- Nursing, including advanced practice nurse faculty and fellows, inpatient and outpatient nurse clinicians, bedside nursing, nurse educator, and nurse manager
- Physicians, including faculty and fellows
- Social work
- Volunteer coordinators and services at the JBC and DH main hospital
IDT meetings are held at the JBC and the DH main hospital to comprehensively review each patient and family being followed by the palliative care team.
Fellows take weekend call about one weekend per month, either at the JBC or the DH main hospital. Fellows transition from direct supervision to indirect supervision on weekends as the year progresses. Additionally, fellows will cover night home pager call for about one night per week to gain experience in responding to palliative care emergencies.
As the year progresses, fellows will receive mentoring and take an active role in serving as a teaching mentor for other learners who are rotating with palliative care.
Jack Byrne Center for Palliative & Hospice Care (JBC) Block
Fellows work in this stand-alone hospice and palliative care unit which serves as an extension of the DH main hospital to collaboratively manage complex end-of-life care in an interdisciplinary fashion. Patients come from the DH main hospital when the focus of care is on comfort, and fellows work in conjunction with local home hospice agencies to both admit from and discharge patients. The fellow will gain experience with terminal agitation, pain crises, and existential crises as well as better understand how the system of respite and General Inpatient Admission (GIP) hospice admissions works.
As the year progresses, fellows will receive mentoring and take an active role in serving as a teaching mentor for other learners who are rotating with at the JBC.
During the hospice rotation, the Fellow acts as part of the hospice team at the Visiting Nurse and Hospice for Vermont and New Hampshire (VNH), a Medicare-certified hospice agency in White River Junction, VT.
MD/DO Fellows will spend 6 weeks focusing on the home hospice context (4 weeks in first half of year, 2 weeks in second half of year) and another 4 weeks working with VNH patients admitted to or discharged from the Jack Byrne Center (GIP or respite status) at DH for a total of 2.5 months hospice experience. The 2 weeks in the second half of the year is designed to be a more independence hospice medical director experience.
APRN Fellows will spend 3-4 weeks focusing on the home hospice context with an additional focus of gaining an understanding for the role of APRNs in a hospice agency and as a clinician of record. APRN fellows will have the same amount of time dedicated to JBC GIP/respite VNH patients as the MD/DO fellows.
Long-term Care Rotation
Fellows are required to spend 4 weeks, or 100 hours, seeing patients with serious illness who reside in a long-term care facility (LTCF). The DH fellowship uses two interdisciplinary LTCF teams – led by Dr. Dacey and Kendal-at-Hanover and Dr. Stadler of the DH GIM Geriatrics service. The fellow spends a 2 week block with each team.
Kendal-at-Hanover is a Continuing Care Retirement Community (CCRC) with a spectrum of independent to assisted living residences, a secure dementia assisted living unit, and a skilled nursing facility. The DHMC Geriatrics Team provides medical direction and patient care at four Skilled Nursing Facilities (SNFs) all of which have wide socioeconomic diversity among the patient population. Both sites offer significant opportunities in goals of care discussions, advance care planning and end of life care as well as providing experience in routine geriatric evaluation and management.
The Fellow participates in evaluation and management of patients. Patients range from fully independent to those with various stages of progressive dementia, and late-stage cardiac, pulmonary, and cancer diagnoses. Fellows will have the opportunity to see patients whose goals range from full aggressive interventions to those wanting to focus solely on comfort. Fellows will take night call during their DHMC Geriatrics Team time in order to gain experience with clinical triage based on goals of care and principles of geriatric care. Backup supervision will be provided by the Geriatrics team for teaching and confirming appropriate clinical plans.
Fellows join chaplaincy and HPM faculty along with CPE interns in the fall to learn more about each discipline and form connections. The fellows will then spend 2 weeks of time with the chaplaincy department and experience the Clinical Pastoral Education (CPE) program run through this department. This experience will include being involved with CPE education, self-reflection and one-on-one reflection with Chaplaincy staff, CPE clinical review and rounding, learning spiritual screening and assessment tools, and observing verbatims by CPE interns. In the late winter/spring, the CPE interns and HPM fellows will join together to learn about Responding to Miracles and have joint simulated encounters.
Pain Clinic Block
The Pain Clinic rotation is a 1-week experience. Fellows take part in the evaluation of patients with chronic pain issues, and gain knowledge and experience in non-opioid management for treatment of pain.
Fellows will rotate at the Children’s Hospital at Dartmouth working with the Complex Care Team seeing pediatric patients with multiple medical issues to learn the principles of pediatric palliative care. In addition, some patients will be seen in their homes or at Cedar Crest, a long term care facility for children with medical needs.
White River Junction VA Block
Clinical exposure to holistic care for patients and their families with advanced serious illness and receiving care through a federally funded VA system. At the VA, fellows will see a mix of inpatient and outpatient palliative medicine consultations. Attention is directed towards pain and symptom management, psychosocial-spiritual issues, and core communication skills in this population with special attention to the unique needs of the Veteran population. Learners are part of daily interdisciplinary team meetings, team and learner specific educational sessions, and rounding with an attending or interdisciplinary team members.