Education For Physicians On End-of-Life Care Research Articles

The impact of a one month palliative care rotation on medical residents working in a tertiary cancer center in Jordan.

168 Background: Palliative care education and training remains inadequate for medical professionals especially in developing countries. We evaluated the impact of a one month palliative care clinical rotation on medical residents’ attitude, competency, and knowledge related to palliative care in a tertiary cancer center in Jordan. Methods: All transitional Internal Medicine residents rotated in a monthly palliative care rotation at King Hussein Cancer Center (KHCC), in Amman, Jordan, were requested to participate in this educational intervention study. A concise curriculum in palliative and end of life care, adapted from the Education for Physicians on End-Of-Life Care (EPEC) Curriculum and delivered by our faculty was piloted as a part of the clinical rotation. Residents spent one month in the inpatient palliative care unit, in addition to 10 hours of classroom interactive sessions. The curriculum comprised of five modules: 1- Principles of palliative care, 2- Pain management, 3- Management of distressing symptoms, 4- Communication skills, 5- End-of- life care. To assess our educational outcomes, we adapted a previously developed instruments by David Weisman and used by the National Residency Education in the United States. All Instruments were completed by each resident before and after the rotation, and included self-assessment of attitude, competency and a knowledge test comprising of 32-items of multiple choice questions. Results: Twenty of 27 (74%) residents who started the palliative care rotation completed the required education and had paired evaluations. There was improvement in all three instruments: 37% improvement in competence (p < 0.0001), 17% Improvement in knowledge (p = 0.015), and 5% improvement in attitude (p = 0.02). Conclusions: The one-month mandatory rotation improved knowledge, attitude and competence related to palliative care for medical residents.

Development and Evaluation of a Palliative Medicine Curriculum for Third-Year Medical Students

To assess the impact, retention, and magnitude of effect of a required didactic and experiential palliative care curriculum on third-year medical students' knowledge, confidence, and concerns about end-of-life care, over time and in comparison to benchmark data from a national study of internal medicine residents and faculty. Prospective study of third-year medical students prior to and immediately after course completion, with a follow-up assessment in the fourth year, and in comparison to benchmark data from a large national study. Internal Medicine Clerkship in a public accredited medical school. Five hundred ninety-three third-year medical students, from July 2002 to December 2007. Pre- and postinstruction performance on: knowledge, confidence (self-assessed competence), and concerns (attitudes) about end-of-life care measures, validated in a national study of internal medicine residents and faculty. Medical student's reflective written comments were qualitatively assessed. Required 32-hour didactic and experiential curriculum, including home hospice visits and inpatient hospice care, with content drawn from the AMA-sponsored Education for Physicians on End-of-life Care (EPEC) Project. Analysis of 487 paired t tests shows significant improvements, with 23% improvement in knowledge (F(1,486)=881, p<0.001), 56% improvement in self-reported competence (F(1,486)=2,804, p<0.001), and 29% decrease in self-reported concern (F(1,486)=208, p<0.001). Retesting medical students in the fourth year showed a further 5% increase in confidence (p<0.0002), 13% increase in allaying concerns (p<0.0001), but a 6% drop in knowledge. The curriculum's effect size on M3 students' knowledge (0.56) exceeded that of a national cross-sectional study comparing residents at progressive training levels (0.18) Themes identified in students' reflective comments included perceived relevance, humanism, and effectiveness of methods used to teach and assess palliative care education. We conclude that required structured didactic and experiential palliative care during the clinical clerkship year of medical student education shows significant and largely sustained effects indicating students are better prepared than a national sample of residents and attending physicians.

Practice patterns of osteopathic physicians providing end-of-life care: a survey-based study.

In 1996, the American Medical Association drafted and organized the Education for Physicians on End-of-Life Care (EPEC) curriculum. Leadership in the osteopathic medical profession has similarly recognized the goals of EPEC-resulting in the development of Osteopathic-EPEC, which incorporates the core tenets of osteopathic medicine. To assess the impact of EPEC training and the integration of osteopathic principles and practice in end-of-life care provided by osteopathic physicians (DOs). Osteopathic physicians who participated in the 2002 and 2003 AOA (American Osteopathic Association) End-of-Life Care-National Osteopathic Workshops were surveyed (N=100) on the use of advance directives and on their application of the tenets of osteopathic medicine, including the use of osteopathic manipulative techniques, for terminally ill patients. More than 90% of responding DOs (n=66) ranked each of the four core tenets of osteopathic medicine as important. Among completed responses, 58 DOs (89%) said they believed the tenets and philosophy of osteopathic medicine better prepared them to provide end-of-life care. Forty-eight DOs (79%) agreed that the use of osteopathic diagnostic and treatment skills augmented their ability to provide quality care for terminally ill patients. Osteopathic physicians indicated that the tenets of osteopathic medicine improve their effectiveness in providing quality end-of-life care to patients. However, fewer than half of surveyed DOs who used osteopathic manipulative techniques to relieve pain and manage the physical symptoms associated with the dying process reported that the techniques are often or always effective.

End-of-Life Care: A Retreat Format for Residents

The challenge of teaching end-of-life care involves finding ways to incorporate both the science and the art of medicine. To develop a curriculum so that internal medicine residents could more effectively (1) elicit patient's values, goals, and preferences for health care at the end of life, (2) communicate "bad news," (3) discuss patient preferences for nutrition and hydration, ventilator withdrawal, and cardiopulmonary resuscitation, (4) prescribe opioids using different routes of administration and, (5) recommend appropriate treatment of symptoms common at the end of life. The daylong retreat utilized case presentations and problems for presenting scientific content and the film Wit to convey information related to communication, whole-patient assessment, and the palliative care approach. Materials from the Education for Physicians on End-of-Life Care (EPEC) project and the film Wit provided the main educational resources. All second-year internal medicine, and family medicine residents, and geriatric fellows from a community hospital in South Carolina attended. The residents positively evaluated the seminar content and format. Pretests and posttests revealed that residents significantly improved their knowledge regarding pain management (p<0.001), symptom management (p<0.001) and whole-patient assessment (p<0.014). Scores on the pretest and posttest related to communication skills did not significantly change (p=0.092). Yet, qualitative postretreat evaluations showed that residents perceived that the retreat would affect their communication with patients and other less easily quantifiable factors. Quantitative methods that work well for documenting scientific principles and learning may not apply as well in assessing the art of medicine.

Commentary

Commentary

"Getting everyone on the same page": nursing home physicians' perspectives on end-of-life care.

To improve understanding of nursing home physicians' perspectives regarding end-of-life care, and to suggest directions for further research. An exploratory qualitative design based on interviews of 12 nursing home physicians, 10 of whom were medical directors. Medical students served as interviewers. A purposeful sampling strategy yielded interviews with 12 physicians. The sample was selected based on "intensity sampling," which seeks information-rich but not extreme cases. Ten of the 12 physicians were nursing home medical directors; all respondents practiced at least 4 years part-time or full-time in a nursing home setting. Respondents varied by age, gender, urban/rural location, and fellowship training (half the sample had completed a geriatrics fellowship). Seven physicians were affiliated with an academic medical center. Four themes were identified in the analysis of the 12 interview transcripts: extensive familiarity with dying; consensus is integral to good end-of-life care; obstacles can interfere with consensus; and advance directives set the stage for conversations about end-of-life care. The importance of consensus, both in terms of prognosis and in developing a palliative care plan, emerged as the major finding. For the 12 physicians in this study consensus about the resident's status and an appropriate care plan are important features of good end-of-life care. Further research is needed to determine if other members of the health care team (i.e., residents, family members, nursing staff, social worker, etc.) also value consensus highly. It will be important to determine what barriers to consensus other team members identify. Based on the understanding generated from this study, a refinement of the general Education for Physicians on End-of-Life Care (EPEC) model describing the relationship between curative and palliative care is proposed for nursing homes. The refinement underscores the points at which the team might consider revisiting consensus about the resident's status and care plan.

Poster 158: Teaching Residents in rehabilitation to communicate bad news to their patients.

Objective: To determine if an educational program can improve a physical medicine and rehabilitation resident’s ability to deliver bad news to patients. Design: Preeducation and posteducation assessment of residents’ communication ability with a standardized patient. Setting: Clinical skills center. Participants: 10 rehabilitation residents (PGY-2 to PGY-4). Intervention: Preeducation experience with a standardized patient with a simulated C6 complete spinal cord injury followed by a 1-hour educational lecture using the American Medical Association’s (AMA) Education for Physicians on End-of-Life Care (EPEC) program on communicating bad news to patients. This was followed by a posteducation experience with the original standardized patient. The person monitoring the session then provided feedback to the resident before a novel standardized patient, who simulated a mother of a patient who had been in a persistent vegetative state for over a year. The monitor and the standardized patient used a standardized checklist to assess the resident’s performance. Main Outcome Measures: Monitor checklist of 8 items: score 1 if done and 0 if not done (max=8, min=0). Standardized patient checklist of 7 items rated on a Likert scale: excellent, 5; very good, 4; good, 3; fair, 2; poor, 1 (max=35, min=7). Results: Monitor checklist: the preeducation mean was 2.9 (95% confidence interval [CI], 1.81–3.99); the posteducation mean was 5.4 (95% CI, 4.377–6.423); and the novel case mean was 5.9 (95% CI, 5.044–6.756) (multivariate test [Hotelling trace], P=.002). Standardized patient checklist: the preeducation mean was 31.4 (95% CI, 29.609–33.191); the posteducation mean was 34.2 (95% CI, 33.636–34.764); and the novel case mean was 27.9 (95% CI, 25.577–30.223) (multivariate test [Hotelling trace], P=.001). Resident survey (5-point scale): worthwhile educational experience was 4.9; I will use what I learned in the future was 4.7; and I would participate again if not compensated was 4.4. Conclusions: A 1-hour lecture on delivering bad news to patients using the AMA’s EPEC program produced a significant change in resident behavior in interaction with a standardized patient. Residents felt that it was a worthwhile educational experience that would help them in their future practice.

Competency in end-of-life care: last hours of life.

Clinical competence, willingness to educate, and calm and empathic reassurance are critical to helping patients and families in the last hours of living. This review adapted from the Education for Physicians on End-of-Life Care (EPEC) Curriculum describes the predictable course that occurs as well as approaches to management. Management principles are the same at home or in a health care institution. However, death in an institution requires accommodations to assure privacy, cultural observances, and communication that may not be customary. In anticipation of the event, it helps to inform the family and other professionals about what to do and what to expect. Care does not end until the family has been supported with their grief reactions and those with complicated grief helped to get care. Care at the end of life is a core competency.

Palliative Care and Hospice Programs

Palliative Care and Hospice Programs

An EPEC weekend.

Education for Physicians on End-of-Life Care (EPEC) is the American Medical Association's project to train physicians about care at the end of life. This new curriculum is initially being taught to 250 physician-trainers, who, in turn, will teach physicians throughout the United States. This article discusses one physician-trainer's reaction to the January 1999, EPEC Regional Conference in Phoenix, AZ.

End-of-Life Care Movement Growing

THE END-OF-LIFE movement is gaining momentum thanks to major grants from the Robert Wood Johnson Foundation. Two of those grants are supporting projects aimed at educating physicians and the public about methods to improve the care of dying patients. In March, the foundation announced a $1.5-million grant establishing the Education for Physicians on End-of-life Care (EPEC) Project to develop a standardized curriculum for the education of physicians in the care of dying patients. The 2-year project is the first major initiative of the American Medical Association's (AMA) Institute for Ethics. The month before, the foundation awarded a $1.7-million grant to a coalition including the AMA and more than 80 major health and consumer organizations to launch an initiative called Last Acts: Care and Caring at the End of Life. The initiative seeks to unite the efforts of these groups to reform current health care practices that adversely affect patients with