Department of Family & Community Medicine

Enhanced Skills Program: Palliative Care 6 Month Goals and Objectives

Through the Palliative Care Enhanced Skills 6 month program, the Resident will develop an understanding of the core principals of Palliative Care and develop clinical skills to practice palliative care in the hospital and community, including the home palliative care setting at an enhanced primary and secondary level. Residents must learn the skills, knowledge, and attitudes related to the management of physical, psychological, social and spiritual needs of dying patients and their families. In order to incorporate the core values of comprehensiveness, continuity of care and centeredness in family medicine, the Resident will incorporate clinical family medicine activities during the residency program.

The following objectives have been adapted from the EFPPEC Postgraduate Family Medicine Common Competencies/Learning Outcomes 2006 and from the University of Toronto Palliative Medicine Residency Program Educational Objectives 2006. The objectives are written in the CanMEDS-FM framework.

THE FAMILY PHYSICIAN IS A SKILLED CLINICIAN-EXPERT

Overall objective:

The Resident will be able to demonstrate effective knowledge, skills and attitudes in dealing with the complex interplay of the physical, psychological, social and spiritual needs of dying patients and their families across different care locations. The Resident will demonstrate the ability to develop a management plan that appropriately balances disease specific treatment and symptom management according to the individual needs of the patient and the family.

1.) The Resident will demonstrate skills in performing a palliative care assessment and consultation.

The Resident will be able to:

a) Perform a complete palliative care assessment including the physical, social, psychological, spiritual and functional parameters for the palliative care patient and their family
b) Communicate the findings both written and verbally

2.) The Resident will be able to demonstrate advanced knowledge, skill and attitude in managing pain in advanced illness.

The Resident will be able to demonstrate knowledge and the application of this knowledge of:

a) Assessment of pain, including the use of validated assessment tools, history- taking skills, physical examination skills, and appropriate ordering and interpretation of investigations
b) The assessment of patients with cognitive impairment
c) The common and less common cancer pain syndromes
d) The basic neurophysiology of pain transmission
e) The pharmacology (pharmakokinetics and pharmacodynamics) of opioids and the effect of concurrent illnesses on the pharmacology of opioids (i.e. chronic renal failure) and adjuvants (i.e. acetaminophen, NSAIDS, anti-depressants, anti- convulsants, steroids, etc.)
f) Selection of appropriate medication, titration, routes of administration
g) Anticipation, identification and management of side-effects
h) The indications for pain management with interventional techniques i.e. nerve blocks, etc.
i) The role of radiation therapy in pain management and the ability to make the appropriate referral for palliative radiation
j) The role of palliative chemotherapy in cancer pain control
k) To be able to identify those patients with addiction issues and manage pain appropriately
l) To be able to manage pain in acute on chronic non-malignant pain in patients with advanced progressive medical illnesses
m) To be able to apply the chronic non-malignant pain management paradigm of prescribing pain medications when appropriate.

3.) The Resident will be able to demonstrate advanced knowledge, skills and attitudes in managing physical symptoms in advanced illness. For each symptom below, the Resident will be able to:

a) Perform and assessment of each symptom (including performing a history using validated assessment tools, a physical exam and ordering/interpreting appropriate investigations)
b) Understand the pathophysiology of each symptom
c) Provide a differential for each symptom
d) Propose a management strategy for each symptom including

  • Nausea and vomiting
  • Constipation/diarrhea
  • Bowel obstruction
  • Anorexia/cachexia
  • Skin and mouth care
  • Weakness and fatigue
  • Dyspnea
  • Pruritus
  • Insomnia
  • Bleeding and thrombosis
  • Anxiety/Depression
  • Delirium

e) Demonstrate an understanding of the role for hydration and nutritional therapies in palliative care patients

4.) The Resident will be able to demonstrate effective knowledge, skills and attitudes in assessing and managing palliative patients suffering from non-malignant illnesses including COPD, HF, CVA, RF, progressive neurodegenerative diseases (i.e. ALS) and dementia.

5.) The Resident will understand the principles of palliative oncological management in patients.

a) Demonstrate a basic knowledge of cancer, with focus on breast, lung, colon, prostate, pancreatic and hematologic cancers. The Resident will have knowledge of the natural history of the above cancers, complications and basic principles of management
b) Demonstrate knowledge of the role of radiation and chemotherapy in the management of palliative patients and knowledge of when to refer to the oncologist/radiation oncologist
c) Demonstrate knowledge of side-effects of palliative radiotherapy and chemotherapy in the palliative patient and basic management of side-effects of these treatments
d) Knowledge of interventional techniques relating to the care of patients with cancer, specifically, the indication for, complications of, and methods of obtaining consults for placement of:

  • Parenteral lines-Hickman catheters, PICC lines, port-a-cath
  • Interventional radiological procedures, such as g-tubes, nephrostomy tubes, esophageal stents, colorectal stents, biliary drainage procedures, vertebroplasty, thoracentesis, paracentesis, indwelling catheter placement, nerve blocks

e) Recognize, describe the pathophysiology of, and management of the following palliative care emergencies/urgencies, including any potential surgical, radiological, and oncological therapy if appropriate:

  • Airway obstruction
  • Catastrophic bleeding
  • Spinal cord compression
  • SVC syndrome
  • Biliary, urinary and bowel obstruction
  • Hypercalcemia

6.) The Resident will have advanced skills in managing pain and symptoms of patients in the last days to weeks of life.

a) Demonstrate knowledge of symptoms and issues arising in the last days and hours of life in any care setting including acute care, hospital, palliative care unit, home and long-term care facility.
b) Demonstrate skills in the management of these symptoms
e) Have knowledge of funeral resources and after death planning

7.) The Resident will monitor the efficacy to symptom management plans

8.) The Resident will be able to demonstrate knowledge, skills and attitudes in managing the psychosocial aspects of advanced illness in a culturally sensitive manner.

The Resident will be able to:

  • Identify psychological, social and spiritual issues associated with life- threatening illness and strategies for management
  • Understand the role of coping styles in dealing with life threatening illnesses
  • Identify and manage anger, fear, and strong affective responses to life- threatening illnesses
  • Identify and manage depression and anxiety
  • Describe the process of normal grief and features of atypical grief
  • To be able to give early bereavement support to families
  • Demonstrate skills in working with and caring for the families of actively dying patients
  • Demonstrate skills in providing education to patients and their families around illness, symptom management and end-of-life decision-making
  • Identify the existential needs of dying patients and their families and the strategies for managing them

9.) The Resident will be able to demonstrate skills in managing patients in their homes.

The Resident will be able to:

a) Describe the community resources available to support dying patients in their homes
b) Describe the physician’s role in the care of the dying patient at home
c) Describe an approach to the care of the dying patient at-specifically addressing, anticipating needs, using alternative routes of medication and understanding the role of the physician at the time of death
d) Demonstrate skill in providing home visits to patients
e) Manage emergency situations in the home setting
f) Develop a proactive and therefore preventative approach to the dying patient’s and family’s needs throughout the course of illness
g) Recognize when it is no longer possible to provide appropriate care to the patient in the home setting and effect the transfer to the appropriate setting
h) Understand and work within the culture of the extended palliative care community they serve.

10.) The Resident will be able to demonstrate skills in managing their patients in the hospital, palliative care unit and hospice setting

The Resident will be able to:

a)  Demonstrate skill in assessing patients in the above settings.
b)  Demonstrate skill in managing patients in the above settings.
c)  Demonstrate the ability to work with inter-professional team members to provide the best care to the patient and family.

11.) The Resident will be able to demonstrate skills in managing pain and symptoms in the community setting in patients with both malignant and non-malignant diagnoses.

The Resident will be able to:

a) Identify patients in the community setting that would benefit from a comprehensive pain and symptom assessment.
b) Demonstrate skill in assessing complex pain and symptom issues.
c) Demonstrate skill in managing complex pain and symptom issues in the community.
d) Demonstrate skill in identifying and referring patients that need expert treatment.

12.) The Resident will be able to describe medical and societal attitudes towards death and dying.

The Resident will be able to:

a) Describe current societal attitudes about death and dying
b) Identify issues in death and dying relevant to different cultures, faiths and traditions
c) Describe current barriers to providing improved care to the dying

13.) The Resident will determine, record, implement and revise goals of care through effective communication with the patient and family.

14.) The Resident will demonstrate the ability to discuss advance care planning, including developing, revising and implementing advance directives with patients and their families.

15.) The Resident will be able to discuss ethical issues confronting dying patients, and their families and healthcare providers, including end-of-life decision-making, advance directives, competency, euthanasia and assisted suicide.

The Resident will be able to:

a) Outline a general framework for ethical decision-making to families where appropriate
b) Describe an approach to addressing particular ethical issues at the end-of-life, including withdrawal or withholding therapy, hydration and nutrition, advance directives, palliative sedation, euthanasia and assisted suicide

THE DOCTOR-PATIENT RELATIONSHIP IS CENTRAL TO THE ROLE OF THE FAMILY PHYSICIAN-COMMUNICATOR

THE DOCTOR-PATIENT RELATIONSHIP IS CENTRAL TO THE ROLE OF THE FAMILY PHYSICIAN-COMMUNICATOR

1.) The Resident will develop rapport, trust and ethical therapeutic relationships with patients and families.

The Resident will be able to:

a) Understand the impact of good patient-physician communication on patient care, patient satisfaction, and clinical outcome
b) Demonstrate skills in patient-physician communication, including active listening, reflection, use of non-verbal cues, etc.
c) Demonstrate skill in discussing end-of-life issues with patients and families, such as treatment choices, location of care and decisions regarding resuscitation d) Demonstrate skill in breaking bad news to patients and families

2.) The Resident will be able to demonstrate skill in developing a shared understanding of a patient’s goals of care and demonstrate an ability to communicate these goals to all the caregivers in the health care team. Goals of care refer to a patient’s beliefs, hopes, expectations and concerns regarding their illness experience.

The Resident will be able to:

a) Participate in and facilitate family meetings to discuss relevant issues such as goals of care and future planning
b) Understand the importance of patient confidentiality
c) Demonstrate skill in addressing challenging communication issues such as anger, misunderstanding and grief reactions
d) Respect diversity and difference, including but not limited to the impact of gender, religion and cultural beliefs in decision-making
e) Demonstrate the ability to adapt communication style with the clinical situation at hand.

3.) The Resident will be able to convey effective oral and written information about a medical encounter.

The Resident will be able to:

a) Maintain clear, accurate, and appropriate records of clinical encounters and plans
b) Effectively present verbal reports of clinical encounters and plans.

4.) The Resident will determine, record, implement and revise goals of care through effective communication with the patient and family.

5.) The Resident will demonstrate the ability to discuss advance care planning, including developing, revising and implementing advance directives with patients and their families.

6.) The Resident will be able to discuss ethical issues confronting dying patients, and their families and healthcare providers, including end-of-life decision-making, advance directives, competency, euthanasia and assisted suicide.

7.) The Resident will demonstrate the ability to manage and/or coordinate care of patients across the health care settings including the appropriate use of referrals.

8.) The Resident will demonstrate the ability to maintain appropriate boundaries with patients and their families.

9.) The Resident will demonstrate the ability to manage extremes of emotion and affect that patients and their family members may express.

10.) The Resident will recognize how experiences with patients and their families may affect their own emotions.

The Resident will:

a) Demonstrate an understanding how their own experience with death and dying may influence their own response to a clinical situation.
b) Identify a mentor(s) with whom they can communicate any concern both clinically and personally.
c) Demonstrate the ability to integrate with a team and use the team as a source of professional support.
d) Demonstrate the ability to reflect on experiences and how they affect themselves both professionally and personally.

THE FAMILY PHYSICIAN IS A RESOURCE TO A DEFINED PRACTICE POPULATION/ FAMILY MEDICINE IS COMMUNITY BASED

1.) The Resident will be able to collaborate as an effective member of an interdisciplinary team.

The Resident will be able to:

a) Describe the roles of other disciplines in the provision of palliative care
b) Be able to describe the role of palliative care to other health professionals
c) Participate in the interdisciplinary care of patients, including family conferences and team meetings
d) Communicate effectively with interdisciplinary team members
e) Communicate effectively and work cooperatively with interdisciplinary teams in a home setting, palliative care unit and acute care institution
f) Understand team function and methods to resolve conflicts within teams.

2) The Resident will be able to consult effectively with other physicians and health care professionals.

The Resident will be able to:

a) Demonstrate effective consultation and communication skills when working with referring physicians and services
b) Effectively communicate their assessments and plans to referring physicians and services

THE FAMILY PHYSICIAN IS A RESOURCE TO A DEFINED PRACTICE POPULATION-MANAGER

1.) The Resident will be able to demonstrate the ability to use his/her time effectively.

2.) The Resident will be able to prioritize clinical duties according to urgency.

3.) The Resident will demonstrate the ability to complete records in a timely manner.

4.) The Resident will be able to demonstrate his/her ability to bill appropriately.

5.) The Resident will demonstrate the ability to access resources to plan for future career planning.

THE FAMILY PHYSICIAN IS A RESOURCE TO A DEFINED PRACTICE POPULATION-HEALTH ADVOCATE

1.) The Resident will be able to demonstrate the ability to act as an advocate within the health care system.

The Resident will be able to:

a) Act as an effective advocate for the rights of the patient and family in clinical situations involving serious ethical considerations
b) Advocate for the needs of patient receiving care throughout the health care system
c) Identify the ethical and professional issues inherent in health advocacy including altruism, social justice, autonomy, integrity and idealism

2.) The Resident will be able to identify the determinants of health for the populations that they serve.

The Resident will be able to:

a) Identify the barriers to adequate palliative care for vulnerable or marginalized patients in their patient population
b) Describe barriers to the effective care of dying patients in different care settings across the community

THE FAMILY PHYSICIAN IS A RESOURCE TO A DEFINED PRACTICE POPULATION-SCHOLAR

1.) The Resident will be able to develop a strategy for life-long learning.

The Resident will be able to:

a) Design, implement and monitor a personal plan for continuing education
b) Understand and practice reflective practice as a learning tool

2.) The Resident will be able to incorporate evidence-based clinical decision-making in caring for palliative care patients.

The Resident will:

a) Access the relevant literature to address a specific clinical question
b) Apply critical appraisal skills to the evidence and integrate it into clinical care

3.) The Resident will facilitate the learning of patients, families, students and other health care professional when appropriate.

The Resident will be able to:

a) Act as an educator to patients and their families around end-of-life issues b) Demonstrate an effective lecture or presentation
c) Participate in medical student and resident teaching

4.) The Resident will participate in a scholarly activity.

The Resident will:

a) Take part in a scholarly activity in an area of their interest
b) Present the results of the above project to the Palliative Team

THE DOCTOR-PHYSICIAN RELATIONSHIP IS CENTRAL TO THE ROLE OF THE FAMILY PHYSICIAN AND THE FAMILY PHYSICIAN IS A RESOURCE TO A DEFINED PRACTICE POPULATION

1.) The Resident will demonstrate a commitment to patient, their profession and society through ethical practice.

The Resident will be able to:

a) Demonstrate appropriate behaviour, such as honesty, integrity, commitment, compassion, respect and altruism
b) Demonstrate a commitment to delivering the highest quality of care
c) Recognize and manage ethical issues in their practice
d) Appropriately manage conflict of interest e) Maintain appropriate relations with patients

2.) The Resident will demonstrate a commitment to participate in profession-led regulation.

The Resident will be able to:

a) Appreciate the professional, legal and ethical codes of practice
b) Fulfill the regulatory and legal obligations required of current practice
c) Demonstrate accountability to professional regulatory bodies
d) Recognize and respond to other’s unprofessional behaviours in practice

3.) The Resident will demonstrate a commitment to physician health and sustainable practice.

The Resident will be able to:

a) Describe his or her own concerns about caring for dying patients and their families
b) Demonstrate how his or her own personal experiences of death and dying influence his or her attitudes
c) Discuss methods of managing his or her own stress associated with caring for dying patients
d) Recognize and respond to other professionals in need.

4.) The Resident will be able to assess and manage end-of-life decision-making and planning using bioethical and legal framework.

The Resident will be able to:

a) Outline a general framework for ethical decision-making
b) Describe an approach to addressing particular ethical issues at the end-of-life, including withdrawal or withholding therapy, advance directives, palliative sedation, euthanasia and assisted suicide
c) The Resident will be able to discuss ethical issues confronting dying patients, and their families and healthcare providers, including end-of-life decision- making, advance directives, competency, euthanasia and assisted suicide.

Niren Shetty MD, CCFP
North York General Hospital, room 375 4001 Leslie Street
Toronto, ON M2K1E1
niren.shetty@nygh.on.ca