Association for Palliative Medicine: 2014 curriculum for undergraduate medical education

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INTRODUCTION

It is estimated that in the first year after qualification, a Foundation Year doctor will, on average, care for around 40 patients who die and an additional 120 patients in the final months of life. The care of patients approaching the end of life and the care of dying patients are thus core skills for all FY doctors, who in practice frequently use the knowledge, skills and attitudes outlined below in relatively unsupervised situations.

All UK Medical Schools include Palliative Medicine in their curricula, although the amount of time allocated is very variable. It is not envisaged that all elements of this curriculum will be taught by Palliative Medicine specialists or delivered within a Palliative Medicine course component: many of the learning outcomes can be achieved through integration with other course components. However, it is recommended that those responsible for coordinating Palliative Medicine teaching ensure that the learning outcomes outlined are covered in the curriculum of their Medical School.

In this document, learning outcomes are categorised as:

  1. “Demonstrate understanding of”: knowledge to be shown.
  2. “Demonstrate ability to”: skills to be shown.
  3. “Demonstrate appropriate attitudes towards”: attitudes to be shown.

By the time of graduation and qualification as doctors, medical students should demonstrate the following learning outcomes.

 

1) Basic Principles

Demonstrate understanding of:

  • Terms “palliative care”, “end of life care”, “life-limiting illness” and “terminal illness”.
  • Demographics of death, including causes and places of death.
  • Range of palliative care patients with cancer and other conditions.
  • Patient priorities and preferences at the end of life.
  • Community services to enable patients to die at home.
  • Frameworks to support end of life care provision
  • Range of palliative care services available.
  • When specialist palliative care services should be involved.
  • Particular needs of children and young adults with life-limiting illnesses.
  • The potential need for palliative care concurrent with active disease management.

 

Demonstrate appropriate attitudes towards:

  • Palliative care as a generic skill and duty of all healthcare professionals, including themselves as future junior doctors.

 

2) Physical Care

 

Disease processes

Demonstrate understanding of:

  • The presentation, natural history and management of; cancer, dementia, progressive neurological, respiratory, cardiac, renal, chronic frailty and other life-limiting conditions.
  • The range of “dying trajectories” and the significance of transition points.
  • The importance and limitations of prognostication and prognostic indicators.

Demonstrate appropriate attitudes towards:

  • The benefits and burdens of investigations, treatments and non-intervention.
  • Decision-making concerning ceilings of care and limits of treatment escalation.
  • Recognition of a dying patient and accepting the refocusing of care provision.
  • The uncertainties in end of life care, particularly in non-malignant disease.
  • The concept of allowing “natural death”.

 

Symptom management: general principles

Demonstrate understanding of:

  • Symptoms may be caused by the disease itself, the treatment or concurrent disorders.
  • Importance of diagnosing the pathophysiology of a symptom for effective management.
  • Range of drug and other options for symptom management.
  • Role of anticipatory prescribing and the drugs commonly used.
    • Demonstrate ability to:
  • Formulate and review an appropriate personalised end of life care plan.
  • Write a prescription for anticipatory symptom management.
  • Write a prescription for a continuous subcutaneous infusion (“syringe driver”).

Demonstrate appropriate attitudes towards:

  • Holistic care: identifying and addressing physical, psychological, social and spiritual needs of patients and their families

Pain

 

Demonstrate understanding of:

  • Different types of pain: nociceptive, visceral, neuropathic and incident.
  • WHO ladder, including adjuvant analgesics.
  • Factors influencing pain: physical, psychological, social and spiritual.
  • “Total pain”; the conflation of physical, psychological, social and spiritual suffering that patients may express as pain.
  • Relative benefits / indications / contra-indications of a limited range of opioids.
  • Principles of opioid conversions.
  • Non-drug treatments: physical, psychological, complementary.

Demonstrate ability to:

  • Assess a patient’s pain and formulate a management plan.

  

Other Symptoms

 

Demonstrate understanding of the assessment and management of:

Gastrointestinal symptoms

  • Nausea, vomiting, constipation, ascites, dysphagia, diarrhoea, bowel obstruction, jaundice, hiccups and anorexia.

Cardiorespiratory symptoms

  • Breathlessness, cough, pleural effusion, haemoptysis.

Genitourinary symptoms

  • Catheter care, bladder spasm, urinary obstruction, urinary incontinence, sexual problems.

Neurological symptoms

  • Raised intracranial pressure, epileptic fits, muscle spasm.

Psychological symptoms

  • Depression, anxiety, fear, confusional states, delirium, insomnia.

Emergencies

  • Superior vena cava obstruction, spinal cord compression, hypercalcaemia, overwhelming pain / distress, severe haemorrhage.

Other symptoms

  • Fatigue, lymphoedema: care of fungating lesions, pressure area, wounds and mouth.

 

Care of the dying patient

 

Demonstrate understanding of

  • Signs indicating that a patient is dying.
  • Stopping of drugs and the management of diabetes.
  • Management of symptoms at the end of life.
  • Ethical, legal and clinical issues of oral nutrition and hydration, clinically-assisted nutrition and hydration, sedation and use of opioids in the dying phase.

Demonstrate ability to:

  • Develop a personalized management plan for the care of a dying patient.

Demonstrate appropriate attitudes towards:

  • Recognition of a dying patient and acceptance of the refocusing of care provision.

 

3) Psychosocial Care

 

Demonstrate understanding of:

  • The difference between sadness and clinical depression.
  • The different responses and emotions expressed by patients and caregivers, including fear, guilt, anger, sadness, despair, collusion and denial.
  • The psychological impact of intractable symptoms.
  • Other disciplines who could help patients to deal with psychological issues.
  • Denial as a coping mechanism.
  • Continuum of loss experienced by patients and caregivers throughout illnesses.
  • Recognising unhelpful and potentially harmful psychological responses.

Demonstrate appropriate attitudes towards:

  • Fostering appropriate hope and achievement of goals other than cure.

 

4) Communication with patients, relatives and others

 

Demonstrate understanding of:

  • Documents available to enable patients to record future care preferences.
  • Importance of timely communication between primary and secondary care, particularly when transferring patients between settings.
  • Methods for sharing clinical information between services while maintaining patient confidentiality, including; patient held records, email, fax, shared electronic records and Electronic Palliative Care Co-ordination Systems (EPaCCS).

Demonstrate ability to:

  • Use communication skills in empathic listening.
  • Elicit a patient’s physical, psychological, social and spiritual concerns.
  • Respond appropriately to patient and lay caregiver concerns.
  • Deliver bad news sensitively and at an appropriate pace for the individual.
  • Deal with difficult questions and challenging conversations.
  • Enable those patients who wish to do so to formulate advance care plans.
  • Discuss DNACPR with patients and lay caregivers.
  • Communicate risk and prognostic uncertainty with patients and lay caregivers.
  • Document care and communicate well between team members to ensure patients receive a consistent message.

Demonstrate appropriate attitudes towards:

  • Respecting that some patients may not wish to know or talk about their prognosis.
  • Maintaining patient confidentiality.

 

5) Social and family relationships

 

Demonstrate understanding of:

  • Social impact of life-limiting illnesses in relation to a person’s family, friends, work and other social circumstances.
  • Needs of partners, families and other carers.
  • Impact of illnesses on body image, sexuality and role.

Demonstrate ability to:

  • Take a narrative family history in order to elicit family myths and scripts in terminal illness.
  • Communicate with and support family members as a group and individually.

 

6) Grief and bereavement

 

Demonstrate understanding of:

  • Importance of identifying those who are bereaved.
  • Models of bereavement, the process of grieving and adjustment to loss.
  • Ways to support a bereaved person both before and after the bereavement.
  • Features of abnormal or complicated bereavement requiring intervention.
  • Impact of bereavement on children and others with special needs. 

Demonstrate ability to:

  • Communicate with and support bereaved people.

Demonstrate appropriate attitudes towards:

  • Integral role of doctors as part of the wider team in caring for bereaved people.

 

 

7) Personal and professional issues

Demonstrate appropriate attitudes towards:

  • Personal emotional impact of palliative care on themselves and colleagues.
  • Personal limitations and asking for help and support.
  • Sources of help in dealing with personal and professional issues.

 

8) Culture, Language, Religious and Spiritual Issues

Demonstrate understanding of:

  • Major cultural and religious practices in relation to care at the end of life and after death.
  • Distinction between an individual’s spiritual and religious needs.
  • Role of the hospital chaplain.

Demonstrate ability to:

  • Elicit and respond to spiritual concerns, seeking help if necessary.

Demonstrate appropriate attitudes towards:

  • Doctors’ personal values and belief systems and how these may influence professional judgements and behaviours.

 

9) Ethical and legal issues

Demonstrate understanding of:

  • GMC ethical guidance including “Treatment and Care Towards the End of Life”.

Demonstrate ability to:

  • Apply ethical frameworks (Beneficence, Non-Maleficence, Autonomy, Justice) to ethical issues at the end of life, including: 
  • Double effect.
  • Requests for euthanasia and assisted dying.
  • DNACPR decisions.
  • Withholding / withdrawing treatment.
  • Withholding / withdrawing clinically assisted nutrition and hydration.

Legal frameworks

Demonstrate understanding of:

  • The law in relation to end of life care.
  • Guidelines produced by the GMC, BMA and Royal Colleges.
  • Capacity to give consent.
  • The Mental Capacity Act (2005) and the role of IMCAs.
  • Deprivation of Liberty Safeguards.
  • The procedures involved in death verification and certification and cremation.
  • The situations when liaison with the Coroner’s office or Procurator Fiscal’s office is required.
  • The procedures for relatives following a death.
  • The law concerning Advance Statements of Wishes, Advance Decisions to Refuse Treatment, Power of Attorney for Health and Welfare.

Demonstrate ability to:

  • Complete a medical certificate of cause of death.
  • Complete a cremation certificate.

 

Dr Stephen Barclay and Prof John Ellershaw

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On behalf of the Association for Palliative Medicine

Undergraduate Education Special Interest Forum

February 2014