Teach MDs to spread palliative care message
KY coalition stresses interdisciplinary approach
One of the highlights to the Kentucky Coalition for Compassionate Care’s Journey’s End project is its training program for physicians and nurses. Education for Physicians on End-of-Life Care (EPEC) not only provides information for professionals, it relies upon doctors and nurses who have gone through the program to spread the gospel of palliative care.
"We all acknowledge that medical schools in this country don’t provide enough education on palliative care. EPEC fills that gap," says Mark Pfeifer, MD, vice dean for clinical services at the University of Louisville’s School of Medicine and principal investigator for the Kentucky coalition.
We’re limited in our ability to reach all physicians and nurses, says Carla Hermann, PhD, RN, an associate professor with the University of Louisville’s School of Nursing and a co-investigator with the project. "It’s expensive to try and reach everyone. This works for us because we can train a few people who will train others."
A good fit
EPEC was developed by the American Medical Association with the grant support of the Robert Wood Johnson Foundation. It was designed to educate all U.S. physicians on the essential clinical competencies required to provide quality end-of-life care.
Rather than reinvent a curriculum to teach physicians about end-of-life care, the Kentucky coalition chose to use EPEC because it fit with its education goals, Hermann says.
The EPEC curriculum consists of four 30-minute plenary modules and 12 45-minute workshop modules. Developers of the curriculum say its value lies, in part, in its practicality and portability. It teaches fundamental skills in communication, ethical decision making, palliative care, psychosocial considerations, and pain and symptom management, Hermann says. The workshop modules include:
• Module 1: Advance Care Planning.
— Define advance care planning and explain its importance.
— Describe the steps of the advance care planning process.
— Describe the role of patient, proxy, physician, and others.
— Distinguish between statutory and advisory documents.
— Identify pitfalls and limitations in advance care planning.
— Utilize planning to help the patient put affairs in order.
• Module 2: Communicating Bad News.
— Know why communication of "bad" news is important.
— Understand the six-step protocol for delivering bad news.
— Know what to do at each step.
• Module 3: Whole Patient Assessment.
— Describe elements of suffering (physical, psychological, social, and spiritual).
— Demonstrate ability to assess.
• Module 4: Pain Management.
— Compare and contrast nociceptive and neuropathic pain.
— Know steps of analgesic management.
— Know use of adjuvant analgesic agents.
— Know use of nonpharmacological approaches.
— Know adverse effects of analgesics and their management.
• Module 5: Physician-Assisted Suicide (PAS).
— Identify root causes of suffering that prompt PAS or euthanasia requests.
— Define PAS and describe its current legal status.
— Explain key steps for responding to requests.
— Understand alternative strategies for addressing a patient’s suffering and fears.
• Module 6: Anxiety, Delirium, and Depression.
— Identify major depression in patients facing the end of life.
— Distinguish major depression from normal reactions.
— Describe management plans for anxiety, delirium, and depression.
• Module 7: Goals of Care.
— Name at least five potential goals of care that patients may have.
— Identify clinical junctures at which priorities should be clarified.
— Discuss how priorities should be determined.
— Know how to assist the patient to identify reasonable goals.
• Module 8: Sudden Illness.
— Describe the features of sudden illness that require special skills.
— Know how to communicate effectively in the face of sudden illness.
— Know how to guide decision making in the face of sudden illness.
— Explain the benefits and risks of using a time-limited trial approach.
• Module 9: Medical Futility.
— List factors that might lead to futility situations.
— Know how to assist in resolving each factor.
• Module 10: Common Physical Symptoms.
— Describe general guidelines for managing nonpain symptoms.
— Explain the impact of symptom control.
— Assess and treat each nonpain symptom.
— Explain how the principle of double-effect applies to symptom management.
• Module 11: Withholding/Withdrawing Treatment.
— List medical orders relevant for terminally ill patients.
— Apply this knowledge to clinical situations.
— Describe common misconceptions about withholding or withdrawing therapy.
• Module 12: Last Hours of Living.
— Prepare and support the patient, family, and caregivers (professional and volunteer) through the dying process.
— Assess and manage the pathophysiological changes of dying.
— Identify and manage initial grief reactions.
• The plenary modules cover:
I. Gaps in End-of-Life Care.
— Describe the current state of dying in America.
— Contrast this with the way people wish to die.
II. Legal Issues in End-of-Life Care.
— Describe legal consensus points.
— List common legal myths and pitfalls.
III. Elements of End-of-Life Care.
— Describe a conceptual framework for suffering.
— Describe the elements of end-of-life care.
— Define palliative care.
— Compare and contrast palliative care to hospice care.
IV. Next Steps.
— List the important themes from the conference.
— Identify barriers to good end-of-life care.
— Develop potential solutions.
While the AMA developed the training program for physicians, Journey’s End has not only included nurses, but encouraged physicians who apply to take the course to recruit nurses and social workers to promote an interdisciplinary approach to improving end-of-life care.
Journey’s End began training physicians and nurses using EPEC last fall. So far, a little more than a handful of physicians and nurses have gone through the program. Project officials hope to have as many as 70 EPEC-trained physicians and nurses by year’s end, and 140 by the time the grant expires.
"The hope is that physicians and nurses will talk openly with their patients, so that the decision to move from a curative mode to comfort care is made in a timely fashion," Herman says.
Pfeifer says because the program is taught by physicians in a variety of specialties, it has the potential for wide appeal among physicians because doctors tend to relate better to physicians in like specialties.
"It’s not designed to create experts, but it educates physicians on the basics. Hopefully, it will generate a fair amount of enthusiasm so that they will share what they have learned."
Hermann stresses that EPEC is only part of its overall plan to educate physicians and nurses. The coalition also hopes to revamp the mandatory teaching curriculum in the state’s medical and nursing schools.
[Editor’s note: For more information about EPEC, contact: The EPEC Project, Institute for Ethics, American Medical Association, 515 N. State St., Chicago, IL 60610. Telephone: (312) 464-4979. E-mail: [email protected].]
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