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Palliative and End of Life Care Education
By Guest Authors Matthew Ellman, MD, Director, End-of-Life Care Skills Training & Susan Larkin, BA, both of Yale School of Medicine
A critical aspect of deficiencies in meeting the palliative care needs of patients and their families is practitioners who lack adequate education and training in comprehensive high quality care. Studies have shown that graduating medical students often do not feel prepared or confident in providing care near the end of life. Health professional schools have tried a variety of educational approaches to teaching palliative and end of life care. At Yale School of Medicine, we have implemented an integrative, experiential approach to teach these clinical skills to medical students. In this article, we want to share an exciting addition to the curriculum introduced last year and expanded for the year ahead.
With support from the Connecticut Cancer Partnership and the CT Department of Public Health, the School of Medicine collaborated with Yale University School of Nursing and the departments of religious ministries and social work and the palliative care service of Yale-New Haven Hospital, to develop this innovative, educational opportunity. In this program, medical and advanced nursing students and chaplain and social work interns participate in an educational activity that has two "blended" components: First, students complete an online web-based interactive clinical case with related didactics. Following this, students participate in a "live" interdisciplinary workshop facilitated by faculty from all four disciplines.
The primary learning objectives of the program are to:
- Understand basic precepts and goals of palliative care.
- Recognize common misconceptions about opioids.
- Identify the importance of addressing the spiritual and cultural needs of a patient with terminal illness and understand how to get these needs met.
- Understand the clinical features of imminent death and how to help the patient and family during this time.
- Recognize the contributions of all health care professionals and understand the importance of the interdisciplinary team in the care of the patient with terminal illness.
In the online case, students enter their responses to questions about diverse clinical challenges in the care of a patient with late-stage breast cancer. Students are challenged to think through the management of physical symptoms, spiritual and culture issues impacting decision making and communication, and the effective use of the interdisciplinary team of care providers.
At the live workshop, in small interdisciplinary groups, students grapple and debate palliative care challenges that cross professional lines, such as:
- How to handle the tension between "hope" and "truth telling" in the care of seriously ill patients.
- Experiences in training or personal life when spiritual or cultural issues impacted clinical care.
- What spiritual or cultural biases might be brought to the care of dying patients.
- How to respond to a patient's request to pray with them.
Students then discuss a clinical case with a new set of medical, cultural, and spiritual complexities and experience firsthand what each professional discipline offers in perspective and expertise in the process of developing a comprehensive plan of care. Faculty from each discipline serve as consultants for the students and role model effective team work.
Student evaluations of the program have been very positive. For many, it is one of very few times they interact with students in other graduate disciplines and they really enjoy this. Our hope is that with this foundation, no matter what fields these students ultimately enter, they will continue to broaden their view of the care of patients and seek opportunity to take advantage of the interdisciplinary team of providers.
For further information about this and related programs and for access to the online case modules, please visit the Yale Palliative and End of life Care Education website.
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In the News
FDA Panel has Advised a Ban on Two Pain Relief Drugs
An FDA advisory panel has recommended removing Percocet (oxycodone + acetaminophen), Vicodin (hydrocodone + acetaminophen), and similar medications from the market because of the risk of liver toxicity. Liver damage is the result of too much acetaminophen (the ingredient in Tylenol). Neither opioid is associated with liver damage. The same panel also recommended lowering the recommended daily dose limit of acetaminophen (now at 4000 mg per day for healthy adults) and reducing the largest over-the-counter tablet to 325 mg ("Extra Strength" tablets are 500 mg). This move, while focused on safety, could have a huge negative impact on pain management. Generic hydrocodone/acetaminophen is the largest selling medication in any class of drugs in the United States. Stay tuned.
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Connecticut Challenge Bike Ride a Success
The 5th Annual Connecticut Challenge bicycle ride to raise funds for cancer survivorship in Connecticut, including the Connecticut Challenge Survivorship Clinic at Yale Cancer Center and the HEROS Clinic, was held on July 25th in Fairfield. It was a beautiful day with plenty of inspiration and good will to go around. There were 480 riders, 29 of them cancer survivors, and 16 cancer survivors amongst the volunteers. In aggregate, they rode thousands of miles through the Fairfield County hill country.
While the ride is over, the fundraising is not. Please donate to
support survivorship programs at Yale and other institutions in
Connecticut. You can make a general donation, donate to a rider, or donate to the Yale HEROS or YCC Hot Wheelers teams.
Learn More >>
Guideline for Persistent Pain in Older Persons
The American Geriatrics Society has released an updated guideline, Pharmacological Management of Persistent Pain in Older Persons.
Learn More >>
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Journal Watch
Balducci L. Supportive care in elderly cancer patients. Current Opinion in Oncology. 2009;21(4):310-317.
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Urban D, et al. The management of cancer pain in the elderly. Critical Reviews in Oncology Hematology. 2009;
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Wyatt E. Life after cancer: The importance of survivorship programs for adults. ONS Connect. 2009, June.
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ONS Connect: Special issue on survivorship.
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Hendrikx JJMA, et al. Methylnaltrexone. The Oncologist. 2009.
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Moore RA, et al. Pregabalin for acute and chronic pain in adults. Cochrane Database Syst Rev. 2009 Jul 8;(3):CD007076.
Read More >>
Webster LR. Screening and stratification methods to minimize opioid abuse in cancer patients. Advances in Pain Management. 2008;2(1):4-8.
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