2014, 36: 441–446
Developing learning outcomes for medical students and foundation doctors in palliative care: A national consensus-seeking initiative in Scotland GORDON T. LINKLATER1,2, JOANNA BOWDEN3,4, LINDSEY POPE5, FIONA McFATTER6, STEPHEN M. W. HUTCHISON1,7, PAT J. CARRAGHER8, JOHN WALLEY9, MARIE FALLON3,10 & SCOTT A. MURRAY3; ON BEHALF OF THE SCOTTISH PALLIATIVE MEDICINE CURRICULUM DEVELOPMENT GROUP
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1
University of Aberdeen, UK, 2NHS Grampian, UK, 3University of Edinburgh, UK, 4NHS Fife, UK, 5University of Glasgow, UK, 6NHS Tayside, UK, 7Highland Hospice, UK, 8Children’s Hospice Association Scotland, UK, 9Accord Hospice, UK, 10 NHS Lothian, UK
Abstract Background: Undergraduate education in palliative care is essential if doctors are to be competent to care for dying patients and their families in a range of specialties and healthcare settings. However, creating space for this within existing undergraduate and foundation year curricula poses significant challenges. We aimed to develop consensus learning outcomes for palliative care teaching in the university medical schools in Scotland. Methods: The General Medical Council (GMC) outlines a number of learning outcomes with clear relevance to palliative care. Leaders from the five Scottish medical schools identified and agreed a small number of outcomes, which we judged most relevant to teaching palliative care and collated teaching resources to support these. Results: Consensus learning outcomes for undergraduate palliative care were agreed by our mixed group of clinician educators over a number of months. There were many secondary gains from this process, including the pooling of educational resources and best practice, and the provision of peer support for those struggling to establish curriculum time for palliative care. Discussion: The process and outcomes were presented to the Scottish Teaching Deans, with a view to their inclusion in undergraduate and foundation year curricula. It is through a strong commitment to achieving these learning outcomes that we will prepare all doctors for providing palliative care to the increasing numbers of patients and families that require it.
Background
Practice points
Internationally, the importance of palliative care is being increasingly recognised, although its provision varies greatly among countries (Ahmedzai et al. 2004). The Scottish National Action Plan for Palliative Care (Scottish Government 2008) and the English End-of-Life Care Programme (Department of Health 2008) both highlighted the need for better education and training of all health professionals in palliative care. In 2006, the Association for Palliative Medicine (APM) of Great Britain and Ireland published a recommended syllabus for medical undergraduates (APM 2006), developed by means of a Delphi study of palliative medicine specialists (Paes & Wee 2008). The document provides a clear framework for palliative care educators but it has been described as ‘‘not achievable in already overloaded undergraduate curricula’’ (Gibbins et al. 2010). In 2009, the UK General Medical Council advised medical schools that students must be able to contribute to the care of patients and their families at the end-of-life, including the
Urgent need for young doctors to be more competent in end-of-life care. Little room for more teaching time in already busy curricula. Building the curriculum upon existing TD learning outcomes allows integration of palliative care teaching into university curricula and highlights that palliative care outcomes can be addressed in other speciality teaching. Many of the learning outcomes will require a spiral curriculum with opportunities for supervised experience in practice.
management of symptoms, practical issues of law and certification, effective communication and team-working (General Medical Council 2009). There is known to be great variation between UK medical schools in terms of the undergraduate
Correspondence: Dr. Gordon Linklater, Consultant in Palliative Medicine, NHS Grampian, Roxburghe House, Ashgrove Road, Aberdeen AB25 2ZH, UK. Tel: 01224 557057; Fax: 01224 557072; E-mail: [email protected] ISSN 0142-159X print/ISSN 1466-187X online/14/50441–446 ß 2014 Informa UK Ltd. DOI: 10.3109/0142159X.2014.889289
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palliative care education that they provide in terms of structure, content and quantity (Field & Wee 2002; Lloyd-Williams & MacLeod 2004; Gibbins et al. 2010). It has also been demonstrated that junior doctors often feel unprepared for dealing with dying patients and their families (Rappaport & Witzke 1993; Herzler et al. 2000; Sullivan et al. 2003; Linklater 2010; Bowden et al. 2013) and that end-of-life care is seen as a particularly important stressor by junior doctors (Calman & Donaldson 1991; Paice et al. 2002; Redinbaugh et al. 2003; Rhodes-Kropf et al. 2005). Over the past year, there has been significant controversy within the UK about the use (and potential misuse) of the Liverpool Care Pathway to support the delivery of end-of-life care in the UK hospitals and primary care (Hawkes 2013). The British media have covered the subject extensively describing many concerning stories of poor quality end-of-life care (Rawstorne 2012). The much-awaited Neuberger report ‘‘More Care, Less Pathway’’ (Department of Health 2013) has recently been published, and one of the key themes to emerge is the need for high quality education and training around endof-life care, starting at undergraduate level. It is made very clear in the report that doctors at all levels, and in all settings and specialties, must have the skills and attributes necessary to support patients at the end-of-life, but importantly also their carers and families. In response to the Scottish National plan and the GMC’s call to advance undergraduate palliative care, a national committee with Scottish Deans’ support was set up in 2011 to develop and promote the teaching of palliative care for medical students and foundation year doctors throughout Scotland. We aimed to develop consensus learning outcomes for palliative care teaching in the university medical schools in Scotland and to provide a forum for discussion, sharing of best practice and educational and assessment resources and mutual support for advocacy of palliative care teaching in the medical schools. This model, again with Scottish Deans’ support, had been successfully used to develop consensus generic learning outcomes for undergraduate medical students across the medical schools in Scotland (Simpson et al. 2002).
outcomes, which we considered were core to palliative care learning. Existing taught palliative care curricula at each medical school were documented and shared within the committee to better understand current practice and available resources within Scotland. We then reviewed our current educational resources against the agreed learning outcomes, mapping available resources (relating to learning, teaching and assessment) to each learning outcome. Importantly, this enabled us to identify outcomes for resources that were lacking. During this process, we reported regularly to the Scottish Educational Deans committee to inform them of our progress and to seek their guidance and support. Finally, we fed back the consensus learning outcomes and mapped available resources approved by the National Deans to each medical school, to encourage each school to review and develop their palliative care learning and assessment.
Results Appendix 1 details the learning outcomes extracted from TD. They are grouped under the three main roles of the doctor and under eight high-level outcomes and more specific outcomes, which we list using bullet points. The paragraphs and specific pages in TD where the high-level outcomes were extracted are noted. We considered that these learning outcomes ideally should exist within a spiral curriculum (Figure 1) with an individual student or doctor revisiting the topics, with supported experience in practice (Harden & Stamper 1999). Table 1 lists some of the teaching resources, learning materials and various other resources now available to all Scottish medical schools to be used to facilitate teaching of the palliative care approach in all other specialties.
Methods Representatives from the Scottish Government, the five Scottish medical schools and Children’s Hospice Association Scotland, met to discuss and propose the best way forward. As the GMC recommends an outcomes-focussed curriculum, we first sought to identify the high level outcomes from ‘‘Tomorrow’s Doctors’’ (TD) that were most appropriate to teach within palliative care. We noted that TD groups its learning outcomes under three (level 2) headings: the doctor as a scholar and scientist; the doctor as a practitioner; and the doctor as a professional. Within each of these headings, the GMC lists a number of general and more specific outcomes that medical students have to be able to display on graduation. All members of the committee examined TD, and over a number of consensus-forming meetings, and within the three headings above, we agreed and selected a small number of outcomes, which we judged most relevant to palliative care. Within each of these, we sought to identify some specific 442
Figure 1. The spiral curriculum (Dundee MBChB School of Medicine Course Information Booklet. University of Dundee Medical School 2012, reproduced with permission).
Consensus palliative care learning outcomes
Table 1. Examples of resources now held in a dropbox for Scottish Medical Schools.
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Short powerpoint presentations Demography of death and dying and illness trajectories of decline International inequalities Dimensions of palliative care: physical, social, psychological and existential Role of palliative care in disease management Nausea and vomiting Pain control and analgesic ladder Opioid toxicity and alternative opioids Terminal care/last days of life care What to do after a death Palliative care – 10 top tips for FY1 Masterclass lecture for FY2 Worksheets to promote individual or group work Social and ethical issues for undergraduates Pain control Nausea and vomiting Recognising the terminal phase End of life care Palliative care assessment: 20 questions Palliative care session for FY1s Other resources Bibliography including palliative care beyond cancer, BMJ spotlight Dignity conserving palliative care, Chochinov List of relevant references List of relevant website addresses Primary Palliative Care Research Group Resources: http://www.cphs.mvm.ed.ac.uk/groups/ppcrg/resources.php Short videos: Palliative care in Africa—four-minute video http://www.youtube.com/watch?v¼UxogvbrNcI4 When I die: lessons from the death zone http://www.youtube.com/watch?v¼S2eUw0CUuMc Twenty takes on death and dying http://www.youtube.com/watch?v¼qEkrrSM1YM0 Life before death: The D word http://www.youtube.com/watch?v¼xX-7J5y9m4M EAPC Award 2013 http://www.youtube.com/watch?v¼IDvetw92gAA&feature¼youtu.be
decade ago (MacDonald et al. 1993; Grauel et al. 1996; Barnard et al. 1999; Clay et al. 2001). More recently, the Association of Palliative Medicine in the UK published an undergraduate curriculum (APM 2006). This curriculum described multiple learning outcomes (62 ‘‘essential’’ and 75 ‘‘desirable’’) divided into basic principles, physical care, psychosocial care, culture, language, religious and spiritual issues, ethics and legal frameworks. It suggests the desirable elements could be covered where medical schools have additional time for palliative care or offer special study options. It has, however, already been noted that medical school curricula may not even have room for additional ‘‘essential’’ outcomes (Gibbins et al. 2010). In contrast, the consensus curriculum presented in this article is considerably briefer (with 8 high-level and 38 low-level outcomes); and as the outcomes are articulated in relation to pre-existing GMC outcomes, they should be more easily integrated into pre-existing university curricula. This allows, and, we hope, facilitates, palliative care outcomes to be addressed in non-palliative care parts of the curriculum using some of the resources listed in Table 1. Whilst most of our consensus outcomes are mirrored in the APM curriculum, it is interesting to note that several of the outcomes we generated are not (or only partially so). These outcomes are largely related to the practical tasks or behaviours specific to the junior doctor role, e.g. explain and demonstrate the use and limitations of a care pathway for end-of-life care; describe and apply the Scottish Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) policy; describe strategies for communicating with the recently bereaved; explain the importance of considering multi-morbidity when prescribing for palliative patients; describe how to access advice from pharmacist or palliative care specialists and complete a structured discharge summary for a palliative care patients.
Discussion The serious consequences of inadequate education in endof-life care have been made clear (Department of Health 2013). Training must begin at the undergraduate level for all, laying the foundations for professional learning and development throughout clinicians’ careers. This curriculum presents the consensus palliative care learning outcomes for undergraduate medical students and Foundation Doctors as developed by the palliative care leads for all five medical schools in Scotland. The learning outcomes are matched to those in TD. There is an expectation that they will be addressed in a spiral curriculum, and some guidance has been given as to those outcomes more relevant to experiential learning in Foundation posts. Many of the outcomes in the curriculum relate to specific tasks relevant to junior doctors, e.g. how to prescribe anticipatory medication, how to access help from pharmacists or palliative care specialists and how to complete death certificates and liaise with the procurator fiscal. There are also broader knowledgebased outcomes, e.g. understanding the palliative care needs of patients with non-malignant diagnoses. Other undergraduate palliative care syllabi have been published, with the majority from North America over a
Strengths and weaknesses of this initiative The main strength of the curriculum development process was that the Palliative Care leads from all medical schools in Scotland were actively involved. This has ensured ownership of the curriculum by the universities and has also facilitated gaining the engagement and support of the Scottish Deans. The process had several other significant benefits. It allowed the sharing of teaching, learning and assessment resources. This prompted the development of a web-based cache (Drop Box) of teaching resources, which can be accessed as necessary by the palliative care leads. It also gave a forum for discussing teaching methods and particular examples of good practice. Perhaps most importantly, it gave support to the Palliative Care Leads who were struggling to raise the profile of palliative care teaching within their institutions. It is important to note that the curriculum development group benefitted from a breadth of experience and perspectives, with representation beyond specialist palliative care (specifically from paediatrics and general practice). The timeliness and relevance of this work to the debate around how we can provide high quality end-of-life care for
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patients in all settings is a significant strength of this work. In ‘‘More Care, less Pathway’’ (Department of Health 2013), the inadequacy and inconsistency of palliative care education is emphasised; by developing and agreeing learning outcomes for use in all Scottish medical schools, we hope to ensure that basic competencies in palliative care are reached by all. In addition, it is possible that a similar approach might be useful in other parts of the UK. The format of the curriculum, presented in relation to existing GMC learning outcomes, makes it easier to incorporate into university curriculum development processes. It is anticipated when mapping palliative care teaching within each university many of the outcomes can (and perhaps should) be addressed out-with specifically badged palliative care teaching. Another major strength of the curriculum is that it explicitly includes foundation training. This emphasises the importance of these outcomes as part of a spiral curriculum, being revisited at different times through a clinician’s development, and that certain outcomes do require experiential learning as the students develop into independent practitioners. This should assist those responsible for the taught aspects of the Foundation Programme to make palliative care teaching relevant to the experiences of Foundation doctors and build on undergraduate learning. There are several limitations to the curriculum. We acknowledge that it was developed on the basis of ‘‘expert opinion’’ and as such risked being subject-centred without due emphasis on learners’ needs or competencies. We did not undertake a more formal curriculum development process, e.g. task analysis or triangulation with learners’ views. Whilst the curriculum presents outcomes, it does not come with explicit recommendations about how these outcomes could or should be achieved. We recognise that undergraduate medical curricula are already stretched and further content can be very difficult to fit in. Acknowledging that much palliative care teaching can be done by generalists should help, but clearly ‘‘signposting’’ palliative care teaching can then become a significant challenge. The web-based teaching resource cache revealed that most universities had teaching material for the more knowledgebased topics, e.g. pain management, but that resources for the more attitudinal/behavioural and innovative learning outcomes, e.g. ethics, self-care, illness trajectories were often absent. Considerable time and effort will be needed to properly maintain this resource, but support has been offered by the Scottish Deans to enable this to happen.
Conclusion The urgent need to improve undergraduate education in palliative care is clear. These consensual learning outcomes provide a clear structure for such teaching to be integrated in core teaching by specialties such as primary care and geriatrics as well as in palliative care and oncology. Their foundation in the GMC’s TD learning outcomes highlights that the principles and practicalities of palliative care are widely relevant. We must engage both generalists and palliative medicine specialists in undergraduate palliative care education if we are to 444
meet the learning needs of tomorrow’s foundation doctors and of the senior doctors that they will ultimately become. These learning outcomes provide a concrete platform for discussions within medical schools. There is potential for such discussions to reveal educational activities, which are being delivered currently, but which have not previously been linked to explicit palliative care outcomes. It is through a strong commitment to helping students achieve these learning outcomes that we will prepare our doctors for providing palliative care to the increasing numbers of patients and families who may benefit. Equally as important, we will also lay the foundations for the lifelong learning in palliative care that they must engage with over the course of their careers.
Notes on contributors DR. GORDON LINKLATER, MBChB, FRCP Edin, MMEd, is a consultant in Palliative Medicine, NHS Grampian, and an Honorary Senior Lecturer in the University of Aberdeen. DR. JOANNA BOWDEN, MBChB, MRCP, MClinEd, is a consultant in Palliative Medicine, NHS Fife, and a Research Fellow in the University of Edinburgh. DR. LINDSEY POPE, MBChB, MRCGP, PGCertMedEd, is a Clinical Senior University Teacher in General Practice and Primary Care, University of Glasgow. DR. FIONA McFATTER, MBChB, MRCP, is a consultant in Palliative Medicine in Ninewells Hospital, NHS Tayside, Dundee. DR. STEPHEN M.W. HUTCHISON, MBChB, FRCP Glasg, MD, is a consultant in Palliative Medicine in Highland Hospice, Inverness, and Honorary Clinical Senior Lecturer in the University of Aberdeen. DR. P.J. CARRAGHER, MBChB, FRCPCH, DRCOG, Dip Pall Med, is Medical Director to Children’s Hospice Association Scotland, Canal Court, 42 Craiglockhart Avenue, Edinburgh. DR. JOHN WALLEY, MBChB, MRCP, is a consultant in Palliative Medicine in Accord Hospice, Morton Avenue, Paisley. Professor MARIE FALLON, MBChB, FRCP Edin, FRCP Glasg, MD, is St. Columba’s Hospice Chair of Palliative Medicine, University of Edinburgh, and Honorary Consultant in Palliative Care, Western General Hospital, Edinburgh. Professor SCOTT A. MURRAY, MBChB, FRCGP, FRCP Edin, MD, is St. Columba’s Hospice Chair of Primary Palliative Care, Primary Palliative Care Research Group, Centre for Population Health Sciences, University of Edinburgh.
Acknowledgements The authors wish to thank Dr John Welsh, Dr Martin Leiper, Dr Alison Morrison, Dr Mark Ford and Dr. Kirsty Boyd for their contributions to the curriculum development group. Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the article.
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Britain and Ireland. Southampton. Available from http://www.apmonline.org/documents/129786422919199.pdf [Accessed 18 June 2013]. Barnard D, Quill T, Hafferty FW, Arnold R, Plumb J, Bulger R, Field M. 1999. Preparing the ground: Contributions of the preclinical years to medical education for care near the end of life. Acad Med 74:499–505. Bowden J, Dempsey K, Boyd K, Fallon M, Murray SA. 2013. Are newly qualified doctors prepared to provide supportive and end-of-life care? A survey of foundation year 1 doctors and consultants. J R Coll Physicians Edinb 43:24–28. Calman K, Donaldson M. 1991. The pre-registration house officer year: a critical incident study. Med Educ 25:51–59. Clay M, Jonassen J, Nemitz A. 2001. A one-day interclerkship on end-of-life care. Acad Med 76:517–518. Department of Health. 2008. End of life care strategy – Promoting high quality care for adults at the end of life. London: Department of Health. Department of Health. 2013. More care, less pathway: A review of the Liverpool care pathway. Available from https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/212450/ Liverpool_Care_Pathway.pdf [Accessed 23 August 2013]. Field D, Wee B. 2002. Preparation for palliative care: teaching about death, dying and bereavement in UK medical schools 2000-2001. Med Educ 36:561–567. General Medical Council. 2009. Tomorrow’s Doctors. London: General Medical Council. Available from http://www.gmc-uk.org/ TomorrowsDoctors [Accessed 18 June 2013]. Gibbins J, McCoubrie R, Maher J, Wee B, Forbes K. 2010. Recognizing that it is part and parcel of what they do: Teaching palliative care to medical students in the UK. Palliat Med 24:299–305. Grauel RR, Eger R, Finley RC, Hawtin C, Keay T, O’Brien 3rd W, Pickens N, Schnapper N, Timmel D, O’Mara A, et al. 1996. Education program in palliative and hospice care at the University of Maryland school of medicine. J Cancer Educ 11:144–147. Harden RM, Stamper N. 1999. What is a spiral curriculum? Med Teach 21: 141–143. Hawkes N. 2013. Liverpool care pathway is scrapped after review finds it was not well used. BMJ 347:f4568. Herzler M, Franze T, Dietze F, Asadullah K. 2000. Dealing with the issue ‘care of the dying’ in medical education – Results of a survey of 592 European physicians. Med Educ 34:146–147.
Linklater GT. 2010. Educational needs of foundation doctors caring for dying patients. J R Coll Physicians Edinb 40:13–18. Lloyd-Williams M, MacLeod RD. 2004. A systematic review of teaching and learning in palliative care within the medical undergraduate curriculum. Med Teach 26:683–690. MacDonald N, Mount B, Boston W, Scott JF. 1993. The Canadian palliative care undergraduate curriculum. J Cancer Educ 8:197–201. Paes P, Wee B. 2008. A Delphi study to develop the Association for Palliative Medicine consensus syllabus for undergraduate palliative medicine in Great Britain and Ireland. Palliat Med 22:360–364. Paice E, Rutter H, Wetherell M, Winder B, McManus IC. 2002. Stressful incidents, stress and coping strategies in the pre-registration house officer year. Med Educ 36:56–65. Rappaport W, Witzke D. 1993. Education about death and dying during the clinical years of medical school. Surgery 113:163–165. Rawstorne T. 2012. My diary of mum’s awful death on the Liverpool Care Pathway: Nurse’s heartrending account of how doctors decided to put her mother on the ‘pathway to death’. Daily Mail. [Accessed 6 August 2013] Available from: http://www.dailymail.co.uk/news/article2220409/My-diary-mums-awful-death-Liverpool-Care-Pathway-Nursesheart-rending-account-doctors-decided-mother-pathway-death.html. Redinbaugh EM, Sullivan AM, Block SD, Gadmer NM, Lakoma M, Mitchell AM, Seltzer D, Wolford J, Arnold RM. 2003. Doctors’ emotional reactions to recent death of a patient: Cross sectional study of hospice doctors. BMJ 327:185–191. Rhodes-Kropf J, Carmody SS, Seltzer D, Redinbaugh E, Gadmer N, Block SD, Arnold RM. 2005. ‘‘This is just too awful; I can’t believe I just experienced that . . .’’: Medical students’ reactions to their ‘most memorable’ patient death. Acad Med 80:634–640. Scottish Government. 2008. Living and dying well: A national action plan for palliative and end of life care in Scotland. Edinburgh: Scottish Government. Simpson JG, Furnace J, Crosby J, Cumming AD, Evans PA, Friedman Ben David M, Harden RM, Lloyd D, McKenzie H, McLachlan JC, et al. 2002. The Scottish doctor – Learning outcomes for the medical undergraduate in Scotland: A foundation for competent and reflective practitioners. Med Teach 24:136–143. Sullivan AM, Lakoma MD, Block SD. 2003. The status of medical education in end-of-life care. A national report. J Gen Intern Med 18:685–695.
Appendix 1. Palliative care learning outcomes selected from ‘‘Tomorrow’s Doctors’’ 2009.
UG—outcomes that should be covered in the undergraduate curriculum. UG/FY—outcomes that will be initially addressed in the undergraduate curriculum but will need further experiential learning in the Foundation Years. FY—outcomes that will be initially addressed in the Foundation Years.
THE DOCTOR AS A SCHOLAR AND A SCIENTIST Applying psychological principles, method and knowledge to medical practice (para 9, page 15). (1) Discuss adaptation to major life changes such as bereavement including abnormal adjustments that might occur. (TD page15) Discuss attitudes to death, dying and bereavement in UK society. UG.
Describe psychological, spiritual, cultural and religious issues in dying and bereavement. UG/FY. Describe ways that support can be offered for dying people and their family, relatives and friends before and after the patient dies. UG/FY. Discuss the importance of family centred palliative care including support for carers and the bereaved. UG. Apply to medical practice the principles, method and knowledge of population health and the improvement of health and healthcare (para 11, page17). (2) Discuss the principles and application of tertiary disease prevention (TD page 17). Describe the demography of dying and death in the UK. UG. Explain why palliative care is relevant for people dying from all progressive conditions, not just cancer; and describe the main trajectories of advanced illness. UG/FY. Analyse the reasons for introducing palliative care in parallel with disease management for patients with an advanced, life limiting illness. UG/FY. Compare and contrast the different dimensions of palliative care needs – physical, psychological, social and spiritual. UG.
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THE DOCTOR AS A PRACTITIONER Diagnose and manage clinical presentation (para 14, page 20). (3) Contribute to the care of patients and families at the end of life, including symptom management, practical issues of law and certification, and effective communication and teamwork. (TD page 21). Describe your experiences of the holistic care of a dying patient and their family. UG/FY. Explain the importance of identifying a dying patient and describe the main clinical signs of advanced illness. UG/FY. Explain use of a care pathway to improve care of the dying patient and their family. UG. Demonstrate the use of a care pathway. Discuss the limitations of these pathways. FY. Describe how to prescribe anticipatory medications to maintain good symptom control. UG. Demonstrate prescribing anticipatory medications to maintain good symptom control. FY. Describe the Scottish DNA CPR policy and how the decision-making framework should be applied in practice. UG/FY. Evaluate the communication challenges of discussing CPR and end of life care/care planning with patients and families (UG/FY) and staff. (FY). Discuss how to respond to psychological and spiritual distress associated with death and dying, including self care for professionals. UG/FY. Describe strategies for communicating with the recently bereaved. FY. Be able to complete relevant medical certificates and legal documents and liaise with the procurator fiscal where appropriate. UG/FY. (4) Respond to patients’ concerns and preferences, and respect the rights of patients to reach decisions with their doctor about their treatment and care and to refuse or limit treatment. (TD page 20). Evaluate the roles and responsibilities of the patient, their family, a welfare attorney and the professional team in decision making at the end of life. UG/FY. Demonstrate an understanding of the reasons why patients may want to consider euthanasia or assisted suicide. UG. Evaluate the ethical, legal and medical dilemmas associated with euthanasia, physician assisted suicide, DNACPR, decisions to refuse treatment and treatment withdrawal; consider application of the GMC guidance on end of life care in clinical practice and the Adults with Incapacity Scotland Act. UG/FY. Prescribe drugs safely, effectively and economically (para 17, page 23). (5) Plan appropriate drug therapy for pain and other common symptoms in palliative care. (TD page 23).
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Explain how to carry out a structured pain assessment and describe the main types of pain. UG. Discuss why oral morphine is the first-line opioid for moderate to severe pain. UG. Explain how to start and titrate oral morphine and how to identify and manage any side effects including opioid toxicity. UG/FY. Explain the indications for second line opioids and list the commonly used second-line opioids. UG/FY. Discuss the reasons for using subcutaneous medication in palliative care. UG/FY. Analyse the impact of common symptoms in palliative care (breathlessness, nausea/vomiting, constipation, delirium and anxiety/distress) and outline their management, including both drug therapy and other measures. UG. Explain the importance of considering multi-morbidity in prescribing for palliative patients. UG. (6) Provide a safe and legal script for controlled drugs and calculate appropriate doses. (TD page 23). Describe how to prescribe opioids safely and write a controlled drug prescription for oral morphine. UG/FY. Explain the need to take account of different potencies when switching between opioids or changing the route of administration of the same opioid. UG/FY. Write a prescription for subcutaneous medication administered via a syringe pump. UG/FY. (7) Access reliable information about medicines used in palliative care. (TD page 23). Discuss how to access and apply Palliative Care Guidelines for symptom control and compare them with the prescribing information in the BNF. UG/FY. Describe how to access advice on palliative care medicines from pharmacists and Palliative Care specialists. UG/FY.
THE DOCTOR AS A PROFESSIONAL Protect patients and improve care (para 23, page 28). (8) Understand the framework in which palliative care medicine is practised in the UK including the organisation of agencies and services (TD page 28). Analyse the central role of primary care in delivering palliative care to the majority of patients who have an advanced, life limiting illness. UG. Discuss the value of structured identification, assessment and care planning for people with palliative care needs in primary and secondary care. UG. Describe the criteria for referral to specialist palliative care and the role of a hospice inpatient unit, community palliative care services, hospital palliative care teams and palliative care day services. UG/FY. Complete a structured discharge summary for a patient with palliative care needs. FY.
Developing learning outcomes for medical students and foundation doctors in palliative care: A national consensus-seeking initiative in Scotland GORDON T. LINKLATER1,2, JOANNA BOWDEN3,4, LINDSEY POPE5, FIONA McFATTER6, STEPHEN M. W. HUTCHISON1,7, PAT J. CARRAGHER8, JOHN WALLEY9, MARIE FALLON3,10 & SCOTT A. MURRAY3; ON BEHALF OF THE SCOTTISH PALLIATIVE MEDICINE CURRICULUM DEVELOPMENT GROUP
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1
University of Aberdeen, UK, 2NHS Grampian, UK, 3University of Edinburgh, UK, 4NHS Fife, UK, 5University of Glasgow, UK, 6NHS Tayside, UK, 7Highland Hospice, UK, 8Children’s Hospice Association Scotland, UK, 9Accord Hospice, UK, 10 NHS Lothian, UK
Abstract Background: Undergraduate education in palliative care is essential if doctors are to be competent to care for dying patients and their families in a range of specialties and healthcare settings. However, creating space for this within existing undergraduate and foundation year curricula poses significant challenges. We aimed to develop consensus learning outcomes for palliative care teaching in the university medical schools in Scotland. Methods: The General Medical Council (GMC) outlines a number of learning outcomes with clear relevance to palliative care. Leaders from the five Scottish medical schools identified and agreed a small number of outcomes, which we judged most relevant to teaching palliative care and collated teaching resources to support these. Results: Consensus learning outcomes for undergraduate palliative care were agreed by our mixed group of clinician educators over a number of months. There were many secondary gains from this process, including the pooling of educational resources and best practice, and the provision of peer support for those struggling to establish curriculum time for palliative care. Discussion: The process and outcomes were presented to the Scottish Teaching Deans, with a view to their inclusion in undergraduate and foundation year curricula. It is through a strong commitment to achieving these learning outcomes that we will prepare all doctors for providing palliative care to the increasing numbers of patients and families that require it.
Background
Practice points
Internationally, the importance of palliative care is being increasingly recognised, although its provision varies greatly among countries (Ahmedzai et al. 2004). The Scottish National Action Plan for Palliative Care (Scottish Government 2008) and the English End-of-Life Care Programme (Department of Health 2008) both highlighted the need for better education and training of all health professionals in palliative care. In 2006, the Association for Palliative Medicine (APM) of Great Britain and Ireland published a recommended syllabus for medical undergraduates (APM 2006), developed by means of a Delphi study of palliative medicine specialists (Paes & Wee 2008). The document provides a clear framework for palliative care educators but it has been described as ‘‘not achievable in already overloaded undergraduate curricula’’ (Gibbins et al. 2010). In 2009, the UK General Medical Council advised medical schools that students must be able to contribute to the care of patients and their families at the end-of-life, including the
Urgent need for young doctors to be more competent in end-of-life care. Little room for more teaching time in already busy curricula. Building the curriculum upon existing TD learning outcomes allows integration of palliative care teaching into university curricula and highlights that palliative care outcomes can be addressed in other speciality teaching. Many of the learning outcomes will require a spiral curriculum with opportunities for supervised experience in practice.
management of symptoms, practical issues of law and certification, effective communication and team-working (General Medical Council 2009). There is known to be great variation between UK medical schools in terms of the undergraduate
Correspondence: Dr. Gordon Linklater, Consultant in Palliative Medicine, NHS Grampian, Roxburghe House, Ashgrove Road, Aberdeen AB25 2ZH, UK. Tel: 01224 557057; Fax: 01224 557072; E-mail: [email protected] ISSN 0142-159X print/ISSN 1466-187X online/14/50441–446 ß 2014 Informa UK Ltd. DOI: 10.3109/0142159X.2014.889289
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palliative care education that they provide in terms of structure, content and quantity (Field & Wee 2002; Lloyd-Williams & MacLeod 2004; Gibbins et al. 2010). It has also been demonstrated that junior doctors often feel unprepared for dealing with dying patients and their families (Rappaport & Witzke 1993; Herzler et al. 2000; Sullivan et al. 2003; Linklater 2010; Bowden et al. 2013) and that end-of-life care is seen as a particularly important stressor by junior doctors (Calman & Donaldson 1991; Paice et al. 2002; Redinbaugh et al. 2003; Rhodes-Kropf et al. 2005). Over the past year, there has been significant controversy within the UK about the use (and potential misuse) of the Liverpool Care Pathway to support the delivery of end-of-life care in the UK hospitals and primary care (Hawkes 2013). The British media have covered the subject extensively describing many concerning stories of poor quality end-of-life care (Rawstorne 2012). The much-awaited Neuberger report ‘‘More Care, Less Pathway’’ (Department of Health 2013) has recently been published, and one of the key themes to emerge is the need for high quality education and training around endof-life care, starting at undergraduate level. It is made very clear in the report that doctors at all levels, and in all settings and specialties, must have the skills and attributes necessary to support patients at the end-of-life, but importantly also their carers and families. In response to the Scottish National plan and the GMC’s call to advance undergraduate palliative care, a national committee with Scottish Deans’ support was set up in 2011 to develop and promote the teaching of palliative care for medical students and foundation year doctors throughout Scotland. We aimed to develop consensus learning outcomes for palliative care teaching in the university medical schools in Scotland and to provide a forum for discussion, sharing of best practice and educational and assessment resources and mutual support for advocacy of palliative care teaching in the medical schools. This model, again with Scottish Deans’ support, had been successfully used to develop consensus generic learning outcomes for undergraduate medical students across the medical schools in Scotland (Simpson et al. 2002).
outcomes, which we considered were core to palliative care learning. Existing taught palliative care curricula at each medical school were documented and shared within the committee to better understand current practice and available resources within Scotland. We then reviewed our current educational resources against the agreed learning outcomes, mapping available resources (relating to learning, teaching and assessment) to each learning outcome. Importantly, this enabled us to identify outcomes for resources that were lacking. During this process, we reported regularly to the Scottish Educational Deans committee to inform them of our progress and to seek their guidance and support. Finally, we fed back the consensus learning outcomes and mapped available resources approved by the National Deans to each medical school, to encourage each school to review and develop their palliative care learning and assessment.
Results Appendix 1 details the learning outcomes extracted from TD. They are grouped under the three main roles of the doctor and under eight high-level outcomes and more specific outcomes, which we list using bullet points. The paragraphs and specific pages in TD where the high-level outcomes were extracted are noted. We considered that these learning outcomes ideally should exist within a spiral curriculum (Figure 1) with an individual student or doctor revisiting the topics, with supported experience in practice (Harden & Stamper 1999). Table 1 lists some of the teaching resources, learning materials and various other resources now available to all Scottish medical schools to be used to facilitate teaching of the palliative care approach in all other specialties.
Methods Representatives from the Scottish Government, the five Scottish medical schools and Children’s Hospice Association Scotland, met to discuss and propose the best way forward. As the GMC recommends an outcomes-focussed curriculum, we first sought to identify the high level outcomes from ‘‘Tomorrow’s Doctors’’ (TD) that were most appropriate to teach within palliative care. We noted that TD groups its learning outcomes under three (level 2) headings: the doctor as a scholar and scientist; the doctor as a practitioner; and the doctor as a professional. Within each of these headings, the GMC lists a number of general and more specific outcomes that medical students have to be able to display on graduation. All members of the committee examined TD, and over a number of consensus-forming meetings, and within the three headings above, we agreed and selected a small number of outcomes, which we judged most relevant to palliative care. Within each of these, we sought to identify some specific 442
Figure 1. The spiral curriculum (Dundee MBChB School of Medicine Course Information Booklet. University of Dundee Medical School 2012, reproduced with permission).
Consensus palliative care learning outcomes
Table 1. Examples of resources now held in a dropbox for Scottish Medical Schools.
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Short powerpoint presentations Demography of death and dying and illness trajectories of decline International inequalities Dimensions of palliative care: physical, social, psychological and existential Role of palliative care in disease management Nausea and vomiting Pain control and analgesic ladder Opioid toxicity and alternative opioids Terminal care/last days of life care What to do after a death Palliative care – 10 top tips for FY1 Masterclass lecture for FY2 Worksheets to promote individual or group work Social and ethical issues for undergraduates Pain control Nausea and vomiting Recognising the terminal phase End of life care Palliative care assessment: 20 questions Palliative care session for FY1s Other resources Bibliography including palliative care beyond cancer, BMJ spotlight Dignity conserving palliative care, Chochinov List of relevant references List of relevant website addresses Primary Palliative Care Research Group Resources: http://www.cphs.mvm.ed.ac.uk/groups/ppcrg/resources.php Short videos: Palliative care in Africa—four-minute video http://www.youtube.com/watch?v¼UxogvbrNcI4 When I die: lessons from the death zone http://www.youtube.com/watch?v¼S2eUw0CUuMc Twenty takes on death and dying http://www.youtube.com/watch?v¼qEkrrSM1YM0 Life before death: The D word http://www.youtube.com/watch?v¼xX-7J5y9m4M EAPC Award 2013 http://www.youtube.com/watch?v¼IDvetw92gAA&feature¼youtu.be
decade ago (MacDonald et al. 1993; Grauel et al. 1996; Barnard et al. 1999; Clay et al. 2001). More recently, the Association of Palliative Medicine in the UK published an undergraduate curriculum (APM 2006). This curriculum described multiple learning outcomes (62 ‘‘essential’’ and 75 ‘‘desirable’’) divided into basic principles, physical care, psychosocial care, culture, language, religious and spiritual issues, ethics and legal frameworks. It suggests the desirable elements could be covered where medical schools have additional time for palliative care or offer special study options. It has, however, already been noted that medical school curricula may not even have room for additional ‘‘essential’’ outcomes (Gibbins et al. 2010). In contrast, the consensus curriculum presented in this article is considerably briefer (with 8 high-level and 38 low-level outcomes); and as the outcomes are articulated in relation to pre-existing GMC outcomes, they should be more easily integrated into pre-existing university curricula. This allows, and, we hope, facilitates, palliative care outcomes to be addressed in non-palliative care parts of the curriculum using some of the resources listed in Table 1. Whilst most of our consensus outcomes are mirrored in the APM curriculum, it is interesting to note that several of the outcomes we generated are not (or only partially so). These outcomes are largely related to the practical tasks or behaviours specific to the junior doctor role, e.g. explain and demonstrate the use and limitations of a care pathway for end-of-life care; describe and apply the Scottish Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) policy; describe strategies for communicating with the recently bereaved; explain the importance of considering multi-morbidity when prescribing for palliative patients; describe how to access advice from pharmacist or palliative care specialists and complete a structured discharge summary for a palliative care patients.
Discussion The serious consequences of inadequate education in endof-life care have been made clear (Department of Health 2013). Training must begin at the undergraduate level for all, laying the foundations for professional learning and development throughout clinicians’ careers. This curriculum presents the consensus palliative care learning outcomes for undergraduate medical students and Foundation Doctors as developed by the palliative care leads for all five medical schools in Scotland. The learning outcomes are matched to those in TD. There is an expectation that they will be addressed in a spiral curriculum, and some guidance has been given as to those outcomes more relevant to experiential learning in Foundation posts. Many of the outcomes in the curriculum relate to specific tasks relevant to junior doctors, e.g. how to prescribe anticipatory medication, how to access help from pharmacists or palliative care specialists and how to complete death certificates and liaise with the procurator fiscal. There are also broader knowledgebased outcomes, e.g. understanding the palliative care needs of patients with non-malignant diagnoses. Other undergraduate palliative care syllabi have been published, with the majority from North America over a
Strengths and weaknesses of this initiative The main strength of the curriculum development process was that the Palliative Care leads from all medical schools in Scotland were actively involved. This has ensured ownership of the curriculum by the universities and has also facilitated gaining the engagement and support of the Scottish Deans. The process had several other significant benefits. It allowed the sharing of teaching, learning and assessment resources. This prompted the development of a web-based cache (Drop Box) of teaching resources, which can be accessed as necessary by the palliative care leads. It also gave a forum for discussing teaching methods and particular examples of good practice. Perhaps most importantly, it gave support to the Palliative Care Leads who were struggling to raise the profile of palliative care teaching within their institutions. It is important to note that the curriculum development group benefitted from a breadth of experience and perspectives, with representation beyond specialist palliative care (specifically from paediatrics and general practice). The timeliness and relevance of this work to the debate around how we can provide high quality end-of-life care for
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patients in all settings is a significant strength of this work. In ‘‘More Care, less Pathway’’ (Department of Health 2013), the inadequacy and inconsistency of palliative care education is emphasised; by developing and agreeing learning outcomes for use in all Scottish medical schools, we hope to ensure that basic competencies in palliative care are reached by all. In addition, it is possible that a similar approach might be useful in other parts of the UK. The format of the curriculum, presented in relation to existing GMC learning outcomes, makes it easier to incorporate into university curriculum development processes. It is anticipated when mapping palliative care teaching within each university many of the outcomes can (and perhaps should) be addressed out-with specifically badged palliative care teaching. Another major strength of the curriculum is that it explicitly includes foundation training. This emphasises the importance of these outcomes as part of a spiral curriculum, being revisited at different times through a clinician’s development, and that certain outcomes do require experiential learning as the students develop into independent practitioners. This should assist those responsible for the taught aspects of the Foundation Programme to make palliative care teaching relevant to the experiences of Foundation doctors and build on undergraduate learning. There are several limitations to the curriculum. We acknowledge that it was developed on the basis of ‘‘expert opinion’’ and as such risked being subject-centred without due emphasis on learners’ needs or competencies. We did not undertake a more formal curriculum development process, e.g. task analysis or triangulation with learners’ views. Whilst the curriculum presents outcomes, it does not come with explicit recommendations about how these outcomes could or should be achieved. We recognise that undergraduate medical curricula are already stretched and further content can be very difficult to fit in. Acknowledging that much palliative care teaching can be done by generalists should help, but clearly ‘‘signposting’’ palliative care teaching can then become a significant challenge. The web-based teaching resource cache revealed that most universities had teaching material for the more knowledgebased topics, e.g. pain management, but that resources for the more attitudinal/behavioural and innovative learning outcomes, e.g. ethics, self-care, illness trajectories were often absent. Considerable time and effort will be needed to properly maintain this resource, but support has been offered by the Scottish Deans to enable this to happen.
Conclusion The urgent need to improve undergraduate education in palliative care is clear. These consensual learning outcomes provide a clear structure for such teaching to be integrated in core teaching by specialties such as primary care and geriatrics as well as in palliative care and oncology. Their foundation in the GMC’s TD learning outcomes highlights that the principles and practicalities of palliative care are widely relevant. We must engage both generalists and palliative medicine specialists in undergraduate palliative care education if we are to 444
meet the learning needs of tomorrow’s foundation doctors and of the senior doctors that they will ultimately become. These learning outcomes provide a concrete platform for discussions within medical schools. There is potential for such discussions to reveal educational activities, which are being delivered currently, but which have not previously been linked to explicit palliative care outcomes. It is through a strong commitment to helping students achieve these learning outcomes that we will prepare our doctors for providing palliative care to the increasing numbers of patients and families who may benefit. Equally as important, we will also lay the foundations for the lifelong learning in palliative care that they must engage with over the course of their careers.
Notes on contributors DR. GORDON LINKLATER, MBChB, FRCP Edin, MMEd, is a consultant in Palliative Medicine, NHS Grampian, and an Honorary Senior Lecturer in the University of Aberdeen. DR. JOANNA BOWDEN, MBChB, MRCP, MClinEd, is a consultant in Palliative Medicine, NHS Fife, and a Research Fellow in the University of Edinburgh. DR. LINDSEY POPE, MBChB, MRCGP, PGCertMedEd, is a Clinical Senior University Teacher in General Practice and Primary Care, University of Glasgow. DR. FIONA McFATTER, MBChB, MRCP, is a consultant in Palliative Medicine in Ninewells Hospital, NHS Tayside, Dundee. DR. STEPHEN M.W. HUTCHISON, MBChB, FRCP Glasg, MD, is a consultant in Palliative Medicine in Highland Hospice, Inverness, and Honorary Clinical Senior Lecturer in the University of Aberdeen. DR. P.J. CARRAGHER, MBChB, FRCPCH, DRCOG, Dip Pall Med, is Medical Director to Children’s Hospice Association Scotland, Canal Court, 42 Craiglockhart Avenue, Edinburgh. DR. JOHN WALLEY, MBChB, MRCP, is a consultant in Palliative Medicine in Accord Hospice, Morton Avenue, Paisley. Professor MARIE FALLON, MBChB, FRCP Edin, FRCP Glasg, MD, is St. Columba’s Hospice Chair of Palliative Medicine, University of Edinburgh, and Honorary Consultant in Palliative Care, Western General Hospital, Edinburgh. Professor SCOTT A. MURRAY, MBChB, FRCGP, FRCP Edin, MD, is St. Columba’s Hospice Chair of Primary Palliative Care, Primary Palliative Care Research Group, Centre for Population Health Sciences, University of Edinburgh.
Acknowledgements The authors wish to thank Dr John Welsh, Dr Martin Leiper, Dr Alison Morrison, Dr Mark Ford and Dr. Kirsty Boyd for their contributions to the curriculum development group. Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the article.
References Ahmedzai S, Costa A, Blengini C, Bosch A, Sanz-Ortiz J, Ventafridda V, Verhagen SC. 2004. A new international framework for palliative care. Eur J Cancer 40:2192–2300. Association for Palliative Medicine of Great Britain and Ireland. 2006. Consensus syllabus for undergraduate palliative medicine in Great
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Britain and Ireland. Southampton. Available from http://www.apmonline.org/documents/129786422919199.pdf [Accessed 18 June 2013]. Barnard D, Quill T, Hafferty FW, Arnold R, Plumb J, Bulger R, Field M. 1999. Preparing the ground: Contributions of the preclinical years to medical education for care near the end of life. Acad Med 74:499–505. Bowden J, Dempsey K, Boyd K, Fallon M, Murray SA. 2013. Are newly qualified doctors prepared to provide supportive and end-of-life care? A survey of foundation year 1 doctors and consultants. J R Coll Physicians Edinb 43:24–28. Calman K, Donaldson M. 1991. The pre-registration house officer year: a critical incident study. Med Educ 25:51–59. Clay M, Jonassen J, Nemitz A. 2001. A one-day interclerkship on end-of-life care. Acad Med 76:517–518. Department of Health. 2008. End of life care strategy – Promoting high quality care for adults at the end of life. London: Department of Health. Department of Health. 2013. More care, less pathway: A review of the Liverpool care pathway. Available from https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/212450/ Liverpool_Care_Pathway.pdf [Accessed 23 August 2013]. Field D, Wee B. 2002. Preparation for palliative care: teaching about death, dying and bereavement in UK medical schools 2000-2001. Med Educ 36:561–567. General Medical Council. 2009. Tomorrow’s Doctors. London: General Medical Council. Available from http://www.gmc-uk.org/ TomorrowsDoctors [Accessed 18 June 2013]. Gibbins J, McCoubrie R, Maher J, Wee B, Forbes K. 2010. Recognizing that it is part and parcel of what they do: Teaching palliative care to medical students in the UK. Palliat Med 24:299–305. Grauel RR, Eger R, Finley RC, Hawtin C, Keay T, O’Brien 3rd W, Pickens N, Schnapper N, Timmel D, O’Mara A, et al. 1996. Education program in palliative and hospice care at the University of Maryland school of medicine. J Cancer Educ 11:144–147. Harden RM, Stamper N. 1999. What is a spiral curriculum? Med Teach 21: 141–143. Hawkes N. 2013. Liverpool care pathway is scrapped after review finds it was not well used. BMJ 347:f4568. Herzler M, Franze T, Dietze F, Asadullah K. 2000. Dealing with the issue ‘care of the dying’ in medical education – Results of a survey of 592 European physicians. Med Educ 34:146–147.
Linklater GT. 2010. Educational needs of foundation doctors caring for dying patients. J R Coll Physicians Edinb 40:13–18. Lloyd-Williams M, MacLeod RD. 2004. A systematic review of teaching and learning in palliative care within the medical undergraduate curriculum. Med Teach 26:683–690. MacDonald N, Mount B, Boston W, Scott JF. 1993. The Canadian palliative care undergraduate curriculum. J Cancer Educ 8:197–201. Paes P, Wee B. 2008. A Delphi study to develop the Association for Palliative Medicine consensus syllabus for undergraduate palliative medicine in Great Britain and Ireland. Palliat Med 22:360–364. Paice E, Rutter H, Wetherell M, Winder B, McManus IC. 2002. Stressful incidents, stress and coping strategies in the pre-registration house officer year. Med Educ 36:56–65. Rappaport W, Witzke D. 1993. Education about death and dying during the clinical years of medical school. Surgery 113:163–165. Rawstorne T. 2012. My diary of mum’s awful death on the Liverpool Care Pathway: Nurse’s heartrending account of how doctors decided to put her mother on the ‘pathway to death’. Daily Mail. [Accessed 6 August 2013] Available from: http://www.dailymail.co.uk/news/article2220409/My-diary-mums-awful-death-Liverpool-Care-Pathway-Nursesheart-rending-account-doctors-decided-mother-pathway-death.html. Redinbaugh EM, Sullivan AM, Block SD, Gadmer NM, Lakoma M, Mitchell AM, Seltzer D, Wolford J, Arnold RM. 2003. Doctors’ emotional reactions to recent death of a patient: Cross sectional study of hospice doctors. BMJ 327:185–191. Rhodes-Kropf J, Carmody SS, Seltzer D, Redinbaugh E, Gadmer N, Block SD, Arnold RM. 2005. ‘‘This is just too awful; I can’t believe I just experienced that . . .’’: Medical students’ reactions to their ‘most memorable’ patient death. Acad Med 80:634–640. Scottish Government. 2008. Living and dying well: A national action plan for palliative and end of life care in Scotland. Edinburgh: Scottish Government. Simpson JG, Furnace J, Crosby J, Cumming AD, Evans PA, Friedman Ben David M, Harden RM, Lloyd D, McKenzie H, McLachlan JC, et al. 2002. The Scottish doctor – Learning outcomes for the medical undergraduate in Scotland: A foundation for competent and reflective practitioners. Med Teach 24:136–143. Sullivan AM, Lakoma MD, Block SD. 2003. The status of medical education in end-of-life care. A national report. J Gen Intern Med 18:685–695.
Appendix 1. Palliative care learning outcomes selected from ‘‘Tomorrow’s Doctors’’ 2009.
UG—outcomes that should be covered in the undergraduate curriculum. UG/FY—outcomes that will be initially addressed in the undergraduate curriculum but will need further experiential learning in the Foundation Years. FY—outcomes that will be initially addressed in the Foundation Years.
THE DOCTOR AS A SCHOLAR AND A SCIENTIST Applying psychological principles, method and knowledge to medical practice (para 9, page 15). (1) Discuss adaptation to major life changes such as bereavement including abnormal adjustments that might occur. (TD page15) Discuss attitudes to death, dying and bereavement in UK society. UG.
Describe psychological, spiritual, cultural and religious issues in dying and bereavement. UG/FY. Describe ways that support can be offered for dying people and their family, relatives and friends before and after the patient dies. UG/FY. Discuss the importance of family centred palliative care including support for carers and the bereaved. UG. Apply to medical practice the principles, method and knowledge of population health and the improvement of health and healthcare (para 11, page17). (2) Discuss the principles and application of tertiary disease prevention (TD page 17). Describe the demography of dying and death in the UK. UG. Explain why palliative care is relevant for people dying from all progressive conditions, not just cancer; and describe the main trajectories of advanced illness. UG/FY. Analyse the reasons for introducing palliative care in parallel with disease management for patients with an advanced, life limiting illness. UG/FY. Compare and contrast the different dimensions of palliative care needs – physical, psychological, social and spiritual. UG.
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THE DOCTOR AS A PRACTITIONER Diagnose and manage clinical presentation (para 14, page 20). (3) Contribute to the care of patients and families at the end of life, including symptom management, practical issues of law and certification, and effective communication and teamwork. (TD page 21). Describe your experiences of the holistic care of a dying patient and their family. UG/FY. Explain the importance of identifying a dying patient and describe the main clinical signs of advanced illness. UG/FY. Explain use of a care pathway to improve care of the dying patient and their family. UG. Demonstrate the use of a care pathway. Discuss the limitations of these pathways. FY. Describe how to prescribe anticipatory medications to maintain good symptom control. UG. Demonstrate prescribing anticipatory medications to maintain good symptom control. FY. Describe the Scottish DNA CPR policy and how the decision-making framework should be applied in practice. UG/FY. Evaluate the communication challenges of discussing CPR and end of life care/care planning with patients and families (UG/FY) and staff. (FY). Discuss how to respond to psychological and spiritual distress associated with death and dying, including self care for professionals. UG/FY. Describe strategies for communicating with the recently bereaved. FY. Be able to complete relevant medical certificates and legal documents and liaise with the procurator fiscal where appropriate. UG/FY. (4) Respond to patients’ concerns and preferences, and respect the rights of patients to reach decisions with their doctor about their treatment and care and to refuse or limit treatment. (TD page 20). Evaluate the roles and responsibilities of the patient, their family, a welfare attorney and the professional team in decision making at the end of life. UG/FY. Demonstrate an understanding of the reasons why patients may want to consider euthanasia or assisted suicide. UG. Evaluate the ethical, legal and medical dilemmas associated with euthanasia, physician assisted suicide, DNACPR, decisions to refuse treatment and treatment withdrawal; consider application of the GMC guidance on end of life care in clinical practice and the Adults with Incapacity Scotland Act. UG/FY. Prescribe drugs safely, effectively and economically (para 17, page 23). (5) Plan appropriate drug therapy for pain and other common symptoms in palliative care. (TD page 23).
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Explain how to carry out a structured pain assessment and describe the main types of pain. UG. Discuss why oral morphine is the first-line opioid for moderate to severe pain. UG. Explain how to start and titrate oral morphine and how to identify and manage any side effects including opioid toxicity. UG/FY. Explain the indications for second line opioids and list the commonly used second-line opioids. UG/FY. Discuss the reasons for using subcutaneous medication in palliative care. UG/FY. Analyse the impact of common symptoms in palliative care (breathlessness, nausea/vomiting, constipation, delirium and anxiety/distress) and outline their management, including both drug therapy and other measures. UG. Explain the importance of considering multi-morbidity in prescribing for palliative patients. UG. (6) Provide a safe and legal script for controlled drugs and calculate appropriate doses. (TD page 23). Describe how to prescribe opioids safely and write a controlled drug prescription for oral morphine. UG/FY. Explain the need to take account of different potencies when switching between opioids or changing the route of administration of the same opioid. UG/FY. Write a prescription for subcutaneous medication administered via a syringe pump. UG/FY. (7) Access reliable information about medicines used in palliative care. (TD page 23). Discuss how to access and apply Palliative Care Guidelines for symptom control and compare them with the prescribing information in the BNF. UG/FY. Describe how to access advice on palliative care medicines from pharmacists and Palliative Care specialists. UG/FY.
THE DOCTOR AS A PROFESSIONAL Protect patients and improve care (para 23, page 28). (8) Understand the framework in which palliative care medicine is practised in the UK including the organisation of agencies and services (TD page 28). Analyse the central role of primary care in delivering palliative care to the majority of patients who have an advanced, life limiting illness. UG. Discuss the value of structured identification, assessment and care planning for people with palliative care needs in primary and secondary care. UG. Describe the criteria for referral to specialist palliative care and the role of a hospice inpatient unit, community palliative care services, hospital palliative care teams and palliative care day services. UG/FY. Complete a structured discharge summary for a patient with palliative care needs. FY.
