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Palliative Medicine competency basedTraining Objectives: Core Curriculum in Palliative MedicineThis curriculum defines minimum standards for trainees in general practice. The list is not necessarily exhaustive, and may be developed further by regional advisers, course organisers, trainers or trainees Physical Aspects of Care1) The Disease Process The doctor should: a) know the definitions of terminal illness and of palliative medicine b) be aware that cancer is not always a terminal illness c) understand that care of persons with a potentially life-threatening disease which may be curable, but in which there is uncertainty (e.g. Hodgkin's disease), requires many aspects involved in palliative medicine d) know the patterns of disease, markers of disease progression and the range of treatments available at each stage of disease, for the following range of diseases: · malignant diseases · acquired immune deficiency syndrome (AIDS) · chronic debilitating neurological conditions; in particular, motor neurone disease (amyotrophic lateral sclerosis) e) understand that patients with other diseases e.g. cardio-respiratory failure, may be terminally ill f) be able to assess critically and re-evaluate the clinical situation as the disease progresses g) be able to anticipate likely potential problems caused either by the disease or by treatments h) have skills in diagnosis and manage incidental conditions and iatrogenic illness 2) Pharmacology The doctor should: a) know that drugs are commonly used for the control of symptoms, their usual frequency of administration, typical dose - range and common adverse effects b) know the various routes by which drugs can be administered and when each is appropriate know the indications for a syringe driver c) know how to set up a syringe driver d) know the compatibility and miscibility of drugs used in syringe drivers e) know the effects of renal or liver failure on metabolism and elimination of drugs commonly used in palliative medicine f) understand the importance of the pharmacokinetics of drugs when prescribing to control persistent symptoms g) be able to weigh up the benefits and risks of different drugs for symptom control; be aware that these may change as a patient's condition deteriorates h) know the equivalent doses of different opioids i) know and be able to recognise the less common adverse effects of drugs used in terminal care 3) Symptom Control The doctor should be able to: a) determine the cause of individual symptoms which may be: · caused by the cancer itself · caused by anti-cancer and other treatments; . related to the cancer and/or debility · caused by a concurrent disorder b) manage each of the symptoms appropriately c) understand the place of palliative surgery, radiotherapy, chemotherapy and hormone therapy Specific symptoms to be considered are: a) pain diagnosis of different types of pain including: · the differentiation between nociceptive and neuropathic opioids · taking a pain history and monitoring · response to treatment, including the use of · pain charts · non-drug treatment · common nerve blocks · the range of treatments for difficult pain problems b) anorexia: · nausea and vomiting · constipation · intestinal obstruction · hiccups · dysphagia c) sore mouth: · candidiasis · mouth care d) cough · dyspnoea e) weakness: · lethargy f) depression and appropriate sadness: · fears and anxieties · acute confusional states (delirium) g) pressure area care: · indications for different topical dressings · controlling smell and local bleeding h) stoma care i) incontinence: · bladder spasm and rectal tenesmus · smell, including the management of fungating lesions j) sexual problems k) lymphoedema l) infections in the immunocompromised patient especially: · HIV infected patients · Post chemotherapy 2) The doctor should be able to manage common emergencies in palliative care: a) hypercalcaemia b) spinal cord compression c) superior vena caval obstruction d) massive haemorrhage The doctor should be able to manage: a) fungating lesions including malodour and choice of dressings b) fistulae c) restlessness in the last days of life d) raised intracranial pressure e) malignant effusions f) iatrogenic disease The doctor should be able to: a) recognise limits of attainable symptom control b) give permission to other carers to fail in attempts to achieve complete symptom control The doctor should demonstrate sills in the appropriate use of: a) syringe drivers b) aids to daily living c) an indwelling epidural catheter d) local anaesthetic and steroid injections e) nebulised local anaesthetics and opioids The doctor should demonstrate an understanding of the role of complementary therapies The doctor should demonstrate an understanding of the place of palliative surgery, radiotherapy and hormone manipulation Psychosocial Aspects of Care1) Social and Family The doctor should: a) be able to assess the differing perceptions and expectations of disease and treatment amongst the various family members b) be able to draw up a family tree (genogram) and understand its uses c) understand the importance of family meetings d) understand the psychodynamics of interpersonal relationships and the changes that can occur in illness 2) Communication Skills The doctor should demonstrate skills towards both patient and family in the following: a) empowering the patient to exercise autonomy b) active listening c) assessment of patient's level of awareness d) informing of the diagnosis and/or deterioration gently and sensitively e) breaking bad news f) dealing with difficult questions g) eliciting and dealing with fears 3) Psychological Responses The doctor should recognise and deal with the following in both patient and family: a) anger b) guilt c) transference d) collusion and conspiracy of silence e) the special needs of children f) responses to loss (grief) that are manifest at various stages of illness The doctor must understand that the patient's perception of hope may not be for a "cure", but instead, for example, a pain free death, honesty or the chance to see a longed-for grandchild 4) Sexuality The doctor should understand: a) the patient's perception of his/her sexuality, including body image and personal appearance, and the effect of the disease on this b) how alterations in libido affect the emotional health of the relationship between a patient and his/her partner c) the need for privacy for patient and family to express affection 5) Grief The doctor should demonstrate an ability to: a) understand the normal process of grief b) recognise the patient's response to loss e.g. of health, of limb, of role in life c) help prepare carers for bereavement d) support the person in grief e) anticipate and identify the complicated grief reaction f) support and manage the person with a complicated grief reaction g) assess the need for the support of other agencies h) recognise children's special needs in bereavement 6) Dealing with Own Feelings There is a need for all doctors to: a) recognise and deal with emotional stress in oneself and others in the primary care team b) identify where general practitioners can obtain support appropriate to their own needs and the value of asking for help c) recognise the source and effects of one's own opinions or judgements onto patients or families d) consider how to deal with the guilt feelings arising from perceived deficiencies in care e) have insight into one's own personal and professional limitations Cultural Issues1) Religious Beliefs The doctor should recognise and consider the importance of, and the effect of: a) the beliefs of the patient, the carers and the doctor on any process of care b) the practices of the major religions as related to death c) helping meet spiritual needs either personally or by referral 2) Cultural Influences The doctor should recognise and consider the important effect of cultural influences including language on all aspects of palliative care Ethical IssuesThe doctor should demonstrate, in practice, respect for the patient as a person, 'autonomy', which involves: a) agreeing priorities and goals with the patient and carers b) discussing treatment options with the patient and jointly formulating care plans c) not withholding information desired by the patient at the request of a third party d) fulfilling the patient's need for information about any treatments e) respecting the patient's wish to decline treatment The doctor should show respect for life and acceptance of death, by understanding that: a) treatment should never have the specific induction of death as its aim b) a doctor has neither right nor duty, legal or ethical, to prescribe a lingering death The doctor should: a) understand the issues which surround requests for euthanasia b) recognise the dangers of professionals making judgements based on factors such as pre-morbid disability or the age of the dying person (e.g. death of handicapped child, death of elderly person) c) aim to do good, 'beneficence', and avoid harm, 'non-maleficence' d) assess the risks versus the benefits of each clinical decision The doctor should understand: a) the right of the individual patient to the highest standard of care within the resources available b) the decisions involved in the allocation and use of resources TeamworkThe doctor must:
Practical IssuesInterface between General Practitioner and Consultant Specialists The doctor should understand:
1) Practical Support The doctor should know how to obtain the following: a) appliances, such as a commode b) occupational therapist assessment for modifications to the home to assist with activities of daily living c) physiotherapy services d) support services available to care for the person dying at home, especially home help, sitter services (day and night), volunteer help with shopping, meals on wheels and specialist nursing (Marie Curie or Macmillan) e) assessment for and provision of wheelchairs and cushions f) the services of a Disablement Service’s Centre for artificial limbs and appliances g) relevant grants, funds and allowances 2) Organisational Issues The doctor should know about: a) controlled drugs procedures - national regulations and local policy b) identification and certification of death c) when to inform the coroner d) cremation regulations e) procedures for relatives following death (and understand how cultural influences may affect this) f) the role of the undertaker g) facilities provided by different place of care: home / hospital/ hospice / other
Training Opportunities for Palliative Care in Hospital Posts commonly approved for Training in General PracticeExperiences and opportunities for teaching on aspects of palliative care can be found in most hospital posts suitable for training towards general practice. This Appendix looks at the commonest posts most often approved for hospital training and identifies specific training objectives for these posts. The list is not exhaustive and other opportunities for training which may arise should not be ignored Accident and EmergencyThe doctor should be competent in the practical aspects of resuscitation, but also have the ability to recognise when resuscitation is inappropriate or has failed. The doctor should demonstrate a working knowledge of legal issues surrounding sudden death and certification of death The doctor should have experience in dealing with aspects of sudden or traumatic death including sudden infant death syndrome, road traffic accidents and suicide. The way bad news is given and the way the immediately-bereaved are supported should be considered Obstetrics and GynaecologyThis post provides opportunities for learning about issues concerned with loss. These include infertility and loss of sexuality, miscarriage, still-birth and the birth of an abnormal baby PaediatricsThe doctor should gain an understanding of: a) the effect of protracted childhood illness/handicap on a family b) the effect of a terminally ill child on a family c) responses of a child to illness d) the impact of a childhood death on a family e) the support required for parents and surviving children when a cot death or other bereavement occurs Medicine/Geriatric MedicineThe doctor should gain an understanding of: (a) issues of ageism and euthanasia (b) the principles of rehabilitation (c) the diagnosis and management of non-malignant death (end stage renal failure, cardiac failure or liver failure) (d) identifying and overcoming problems in communication due to sensory deficit, e.g. deafness, visual impairment, and motor dysfunction e.g. dysarthria General SurgeryThe doctor should gain an ability to: a) recognise when curative treatment should be stopped and palliative medicine takes over b) evaluate the place of palliative surgery c) manage inoperable symptoms PsychiatryThe doctor should gain an understanding of the stigma of disease The doctor should be able to demonstrate the ability to identify and manage: a) normal and complicated grief reactions b) psychiatric symptoms associated with terminal illness c) organic psychoses, including drug related psychoses d) depression and adjustment disorder, including appropriate sadness The doctor should have the opportunity to develop his/her communication skills, in particular the skill of active listening Hospice PostsSeveral hospice SHO posts are used for vocational training for general practice. A trainee in such a post should expect to have gained experience in all areas covered in these recommendations. It is to be hoped that the trainee will have obtained a deeper knowledge of some aspects of palliative medicine Higher Professional Training of Established Principals in General PracticeThose doctors who have a particular interest in this aspect of medicine can pursue this as an established principal in general practice, e.g. by participation in various courses such as the Diploma in Palliative Medicine, University College of Wales.
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