Curriculum Areas
Curricula Area - Palliative Medicine and Hospice Care
Syllabus - Palliative Medicine and Hospice Care
Location:
- UT Medical Center, Various Floors
Faculty:
- Ronald Lands, MD, Internal Medicine & Family Medicine
- John Cowan, MD, Medical Director, University Palliative Care
- Teresa Palmer, APN, University Palliative Care
- Cynthia Pearman, MD, Family Medicine
Schedule: Typically Monday – Friday, 8 AM until 5 PM; See Syllabus for detailed schedule.
The resident will attend Morning Report and Noon Conference daily. The resident will attend Grand Rounds and Morbidity and Mortality Conference. The resident will attend a multidisciplinary patient care conference held each Tuesdays at 2:00 pm in the Executive Conference Room, fourth floor.
Primary Goals
Patient Care: Residents will:
- Demonstrate skills in obtaining a thorough and relevant history by review of the medical record, performing a comprehensive physical examination, identifying symptoms, co-morbidities, medications or social influences that impact the palliative care plan
- Be proficient in helping patients and families negotiate goals of care when facing life limiting illness by formulating specific patient centered palliative care plans that include pain management; integration of psycho-social, spiritual and other support services and discharge planning
- Conduct effective and compassionate family meetings
- Formulate a communication plan for delivering prognostic information
- Demonstrate skill in identifying and alleviating symptoms commonly experienced by dying patients
- Demonstrate effective communication with patients and family respecting patients and family wishes regarding patient’s values and goals of care
- Be proficient in evaluating and documenting the care of patients at the end of life
- Recognize and address the psychosocial effects of complex, acute life threatening illness in hospitalized patients
- Anticipate adverse effects from interventions and initiate measures to minimize them
- Direct individual patient’s palliative care delivery from admission to discharge
Medical Knowledge: Residents will be able to:
- Describe the basic philosophy of hospice and palliative medicine.
- Describe Medicare and Medicaid’s hospice benefits.
- Understand the current limits of prognostication for disease states commonly encountered in palliative care.
- Explain the role of palliative care through the natural history of an illness and how it does not compete with curative or restorative treatments that may be necessary, too.
- Understand the range of appropriate options for relieving symptoms commonly experienced by dying patients, including therapies for relieving pain, dyspnea, stress, constipation, nausea, vomiting, fatigue, opiod toxicity, delirium, anxiety, depression and insomnia.
- Describe potential adverse effects from medicines and procedures used in palliation.
- Learn to assess the impact of interventions including feeding tubes, TPN, mechanical ventilation, intravenous fluids on patient comfort and prognosis.
- Be knowledgeable in relevant legal and ethical principles for alleviating suffering using opiods, (e.g. the concept of double effect.)
- Describe the signs and symptoms of the last 24 hours of life and how to discuss these observations with family.
- Understand principles about advanced directives, DNR, healthcare power of attorney.
- Understand controversies in palliative care, including physician assisted suicide, euthanasia, vegetative state, brain death, withholding versus withdrawing care, futility, and terminal sedation.
- Understand principles of psychosocial and spiritual assessment.
- Understand the process of bereavement.
- Demonstrate skill in treating medical co-morbidities and complications in dying patients.
- Demonstrate understanding of the assessment and treatment of neuro-psychiatric problems in dying patients.
- Describe the responsibilities of the physician after a patient dies including pronouncing a person dead, completing the death certificate, requesting an autopsy, notifying family and PCP and contacting the organ donor network.
Professionalism: Residents must:
- Demonstrate commitment to carrying out professional responsibility, adherence to ethical principles and sensitivity to a diverse patient population as described in the general curricular overview as it relates to caring for patients with chronic incurable diseases and those at the end of life.
Practice Based Learning: Residents will:
- Investigate and evaluate their care of patients at the end of life.
- Use evidence-based medicine to care for patients and families dealing with palliative care end of life issues.
- Use information technology to support self-learning in palliative medicine and end of life care.
- Be involved in teaching palliative care concepts to medical students and residents with whom they interact.
Interpersonal and Communication Skills: Residents must:
- Be able to demonstrate interpersonal and communication skills that result in effective information exchange with patients, their patients' families, professional associates.
- Determine the existence of advanced directives and provide patients and families with resources to understand and execute such directives.
- Address resuscitation status and patient preferences for care early during hospital stay.
- Convey diagnosis, prognosis, treatment and support options available for patients and families in a clear, concise, compassionate, culturally sensitive and timely manner.
- Determine patient and family understanding of severity of illness, prognosis and their role in determining the goals of care.
- Promote the ethical imperative of frequent pain assessment and adequate control
- Appreciate that all pain is subjective and acknowledge patient’s self reports of pain.
- Discuss with patient and families goals for pain management strategies and functional status and set targets for pain control.
- Conduct meetings with patients and caregivers to establish goals of care that reflect the patient’s wishes.
- Recognize the need for frequent family meetings.
- Must appreciate that good palliative care for patients with certain conditions often involves the use of therapies typically thought of as curative.
- Advocate incorporation of patient wishes into care plans.
- Maintain rapport with patients and families and a consistent approach to management during transfers of care.
- Recognize impact of cultural and spiritual factors to the provision of palliative care.
Systems-based practice: Residents must:
- Demonstrate an understanding of the context and systems in which end of life care is provided and use this understanding to improve and optimize care.
- Understand, access, and utilize the resources, providers and systems available to patients at end of life.
- Understand limitations of resources available to patient at the end of life and develop strategies to optimize care.
- Apply evidence based and cost conscious strategies for end of life care.
- Collaborate with other members of health care team to care for patients at the end of life.
- Document patient and family discussions, care decisions and other important information in order to promote safe, effective care consistent with the patients and family’s wishes.
- Residents will demonstrate effective participation in teams. They will understand the physician’s role in the team process. They will appreciate the role of other members of the team, including nursing and social services, pharmacy, psychology and pastoral care in providing comprehensive palliative care and work closely with these team members in caring for patients with serious, chronic and terminal illnesses and their families.
Primary Objectives
Overview:
Each resident in the palliative care rotation will become proficient in the principles of palliative care when caring for patients who are nearing the end of life with chronic, incurable and acute illness. Selected readings, didactic lectures, focused discussion and supervised care of palliative care patients and those at the end of life will be the venues of learning. Faculty will teach palliative care and evaluate the resident’s knowledge and proficiency in applying palliative care while supervising the residents in the inpatient setting.
The resident will:
- Set up and run a family meeting that includes a discussion of end of life goals of care during this rotation. Residents will describe the family meeting in the medical record and include a description of the meeting organization, members present, goals and plan.
- Attend lectures and use other educational materials covering management of pain, management of non-pain symptoms, and other appropriate topics.
- Be familiar will be familiar with and use information about palliative care available through the web.
Residents are expected to:
- Create and sustain a therapeutic and ethically sound relationship with patients.
- Use effective listening skills and elicit and provide information using effective non-verbal, explanatory questioning and writing skills.
- Work effectively with others as a member or leader of a health care team or other professional group including members of the team their patient chooses.
Supplemental References, Suggested Readings:
Palliative Care. R, Sean Morrison MD and Diane Meier MD,
NEJM 350; 25, June 17, 2004, Pages 2582-2590.
UniPac Series: AAHPM, Volumes 1-9; Hospice and Palliative Care Training for Physicians, 2008.
Pocket Guide to Hospice/Palliative Medicine, AAHPM
Other Resources: UT Home Health and Hospice
Method of Resident Evaluation:
- The attending physician will meet with each Resident at the beginning of the rotation to review rotation objectives and to elicit the personal goals of the Resident.
- Direct supervision: The attending will provide on-going feedback to residents throughout the rotation.
- Summative evaluation will be provided at the end of each rotation and submitted through New Innovations.
Method of Specialty Evaluation:
Residents are asked to provide direct feedback to the attending in an informal manner during the course of the rotation. They will complete a formal evaluation using New Innovations at the rotation end. Cumulative feedback to the attending faculty member will be given during the annual faculty evaluation by the Departmental Chair in a non-identifying manner. The resident will participate in a once yearly program evaluation.
Feedback:
The attending physician will provide feedback to the Resident frequently during the rotation, addressing the evaluation of the patient, the interpretation of information and the implementation of the plan of care. The attending physician will provide written feedback at the end of each rotation using New Innovations.
Syllabus - Palliative Medicine and Hospice Care
Updated Fall 2009
The University of Tennessee Graduate School of Medicine
1924 Alcoa Highway Box U-114
Knoxville, TN 37920
Phone (865) 305-9340
Fax (865) 305-6849