EPEC gets financial boost to continue doc training
AMA’s comprehensive end-of-life curriculum
The country’s largest effort to educate physicians in end-of-life care has gotten a significant financial boost from the Robert Wood Johnson Foundation (RWJF). The continuing education program, Education for Physicians on End-of-Life Care (EPEC), recently received $991,000 in renewed funding from the RWJF and moved its operation to Northwestern University Medical School in Chicago.
Under the new grant, EPEC will conduct two training sessions and one faculty development conference. It will continue consulting with physicians interested in conducting EPEC sessions at local hospitals, state and county medical society meetings, and regional training conferences.
EPEC, founded four years ago by the American Medical Association (AMA), has produced a thorough end-of-life curriculum including trainer and participant manuals, trigger tapes, and slide sets. The curriculum presents core material in end-of-life care and offers guidance on teaching these palliative care skills to colleagues. The EPEC curriculum is available on the Internet and has been distributed on CD-ROM to AMA members, as well as state, county, and specialty medical societies. Directors of residency programs and deans and department chairs of all U.S. medical schools have also received the materials.
Filling in the end-of-life gap
Many organizations have relied on the AMA-developed curriculum to fill the educational gaps found in today’s medical schools and nursing programs. In an effort to improve end-of-life care in their own states, RWJF-funded projects have implemented EPEC in their statewide educational programs with the hope that EPEC-trained physicians will pass along their new-found palliative care knowledge to their colleagues. The EPEC curriculum consists of the following modules:
Module 1 — Advance Care Planning:
• Define advance care planning and explain its importance.
• Describe the steps of the advance care planning process.
• Describe the roles 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 physical, psychological, social, and spiritual elements of suffering.
• Demonstrate ability to assess each.
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, Depression:
• Identify major depression in patients facing the end of life.
• Distinguish major depression from normal reactions.
• Describe management plans for depression, anxiety, and delirium.
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.
Legal elements and next steps
The Plenary modules cover the following:
Gaps in End-of-life Care:
• Describe the current state of dying in America.
• Contrast this with the way people wish to die.
Legal Issues in End-of-life Care:
• Describe legal consensus points.
• List common legal myths and pitfalls.
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 with hospice care.
Next Steps:
• List the important themes from the conference.
• Identify barriers to good end-of-life care.
• Develop potential solutions.
AMA partnership
The renewed grant and the move come during a new phase for EPEC. In this new phase, EPEC will work with various groups as partners in establishing and perpetuating quality end-of-life care in the medical profession.
"EPEC has made significant progress reaching physicians nationwide and building enthusiasm for improving palliative care knowledge and skills," says RWJF senior program officer Rosemary Gibson. "The continued commitment of the AMA to improving care at the end of life is a tribute to the project’s success and to the AMA’s own recognition of the ongoing work needed to meet the needs of patients and families."
The AMA will continue its founding partnership with EPEC by providing an information resource on EPEC and its activities, and providing EPEC materials at cost. Information is available on the AMA Web site (www.ama-assn.org).
EPEC’s director, Linda Emanuel, MD, PhD, was named director of the Interdisciplinary Program in Professionalism and Human Rights. The professional staff that worked with her on EPEC will also move to Northwestern. The program’s advisory board and expert trainers will continue to come from various institutions.
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