Transcript Palliative Care Curriculum

QMUL Medical student teaching
Dr Hattie Roebuck
Consultant in Palliative Medicine
Honorary Clinical Lecturer QMUL
Outline
• National developments in Palliative Care
• GMC Curriculum requirements on End of Life Care
• Current palliative care curriculum at QMUL
• Suggestions
Background
• UK population becoming more elderly
• 1 in 3 hospital pts are in last year of life
• FY1’s will care for 40 dying patients & 120 in the last year of life
•
Clark D Palliative Medicine May 2014
• Jane Gibbins et al ‘Why are newly qualified doctors unprepared to
care for patients at the end of life?’
• Qualitative study with 21 doctors at end of FY1 from 17 medical
schools – interviewed till saturation of themes
•
Medical Education Journal 2011; 45: 389-399
• ‘I don’t remember being taken to see dying pts… you’re taken to see people
with signs…That’s the thing with a medical student, ‘This person has got
really good signs’, not ‘this person is dying go and see them’.
• ‘they tried to drum into us what palliative care was about, but not how to
do it…. Which hasn’t helped me as a new doctor in the middle of the night’
• Not all consultants/registrars know how to do EOLC – FY1’s learn this
themselves, often from nurses or palliative care teams, learn on the job
Liverpool Care Pathway Misuse
• Liverpool care pathway discredited
• More Care Less pathway
• -> One Chance to get it Right
• Francis report
– Embedding common values and
culture
– Putting the patient first
– Caring for the elderly
– Caring compassionate & considerate
nursing
One Chance to Get it Right.
When it is thought that a person may die within the next few days or
hours, the five Priorities for Care are:
•
This possibility is recognised and communicated clearly, decisions made and
actions taken in accordance with the person's needs and wishes, and these are
regularly reviewed and decisions revised accordingly.
•
Sensitive communication takes place between staff and the dying person, and
those identified as important to them.
•
The dying person, and those identified as important to them, are involved in
decisions about treatment and care to the extent that the dying person wants.
•
The needs of families and others identified as important to the dying person are
actively explored, respected and met as far as possible.
•
An individual plan of care, which includes food and drink, symptom control and
psychological, social and spiritual support, is agreed, co-ordinated and delivered
with compassion
Changes to the law regarding DNACPR
Changes to the law regarding DNACPR
• Legal obligation to discuss
• Recent court case regarding care given to Janet Tracey
• Not informed of DNACPR decision -> engaged Article 8 of European
convention of Human rights (Right to respect for Private & Family
Life)
• ‘Doctors should be wary of being too ready to exclude patients from
discussions due to possible distress – would need to feel harm would
occur’
• However, if CPR will not work, the patient cannot require a doctor
to provide CPR.
Background
• 75% of UK deaths due to non-malignancy
• Are those with a poor prognosis identified?
• Identification allows patients and their families to prepare, referral
to palliative care made, advance care plans to be developed
• Pts with cancer & non cancer illness in last year of life are likely to
be symptomatic
• Identifying exactly when death will occur
hard especially in non malignancy
• But several clinical tools are available that
use indicators that can suggest poor
prognosis
Symptom prevalence in advanced disease
(Solano, Gomes & Higginson, Journal Pain & Symptom management. Jan 06)
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Cancer
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Pain
Confusion
Anorexia
Fatigue
Anxiety/depression
Dyspnoea
Insomnia
Nausea
35-96%
6-93%
30-92%
32-90%
3-79%
10-70%
9-69%
6-68%
•
Cardiac failure
•
•
•
•
•
•
•
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Dyspnoea
Fatigue
Pain
Anxiety/depression
Insomnia
Nausea
Constipation 38-42%
Anorexia
60-88%
69-82%
41-77%
9-49%
36-48%
17-48%
21-41%
Advance care planning
Different forms of advance care plans:
• Preferred Place of Care, Preferred Place of Death
• Advance Statement of Wishes (values, priorities)
• Advance Decision to Refuse Treatment
• Decisions regarding resuscitation
• Lasting Power of Attorney
Advance care plans only come into effect when patient has lost
capacity
Differs from care planning in that it anticipates a deterioration in the
patients health
What about the Medical students
What about the Medical students ?
• 5% of medical students will have had a significant bereavement in
the past year
• Equates to 25% over the course of time at med school
What about the Medical students
• GMC Tomorrows doctors
• 14 Contribute to the care of patients and their families at the end of
life, including the management of symptoms, practical issues of law
& certification, and using effective communication and team
working
• GMC Preparedness for practice report 2014
• Potential weakness in preparedness of FY1s in:
• End of Life Care, communication skills, and involving patients and
families in decision making
Current QMUL Core Palliative Care Teaching
Current QMUL Core Palliative Care Teaching
• Year 2 – Lecture ‘What is
palliative care?’
• Year 3
• Death & Dying morning –
Lecture: sociology of death
• Lecture on bereavement
• Expert panel
• Oncology
Hospice half day
• Lecture: Explaining hospice &
palliative care services
• MDT Speed date
• Lecture: Nausea & Vomiting
• Goldfish bowl
• Year 4
• Lecture: Symptom control in the dying patient
• Healthcare of Elderly firm – palliative care teaching being
developed
• Year 4
• Lecture: Symptom control in the dying patient
• Healthcare of Elderly firm – palliative care teaching
Year 5
• Hospice half day
• Lecture: Recognising & managing dying
• Lecture: Pain management
• Task based / simulated tutorials: managing a dying pt.
• Communication skills teaching Breaking bad news
• Palliative care prescribing teaching
Tomorrows Doctors 2009
•
Contribute to the care of patients & families at the end of life, including symptom
management, practical issues of law & certification, & effective communication &
teamwork (page 21)
•
Plan appropriate drug therapy for common indications including pain & distress
(page 23)
•
Respond to patients’ concerns & preferences, & respect the right of patients to
reach decisions with their doctor about their treatment & care and to refuse or
limit treatment (page 20)
•
Discuss adaption to major life changes such as bereavement (page 15)
•
Provide a safe & legal prescription for medications & calculate appropriate doses
(pg 23)
Access reliable information about medicines (pg 23)
•
Suggestions for GP teaching topics
Suggestions for GP teaching topics
• Year 3
• Case Reflection – meet patient/
family. Take history, reflect on impact on
pt / family, impact on student, learning –
what will take to future cases
• Roles of MDT– DN/ GP/ inpatient
hospice/ community palliative care nurse
• Identification of those in last
year of life - SPICT tool, attend GSF
meetings / frail elderly MDTs, role of
advance care planning
• ?? Ethnic diversity
Suggestions for GP teaching topics
• Year 5
• www.pallied.com
• Meeting palliative/ EOLC pts
• Managing a death in
community
• Practice at writing:
– DNACPR
– Death certification
– Controlled drug prescription
• Safe use of opioids
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Summary
UK population getting older
All doctors need to know how to deliver palliative care
Students may not get the opportunity to meet dying patients
Identifying poor prognosis enables better care
• Significant proportion of students bereaved
• Increased GMC focus on end of life care teaching
Suggestions for GP teaching topics
• Year 3
• Case Reflection – meet patient/
family. Take history, reflect on impact on
pt / family, impact on student, learning –
what will take to future cases
• Roles of MDT– DN/ GP/ inpatient
hospice/ community palliative care nurse
• Identification of those in last
year of life - SPICT tool, attend GSF
meetings / frail elderly MDTs, role of
advance care planning
• ?? Ethnic diversity
• Year 5
• www.pallied.com
• Meeting palliative/ EOLC pts
• Managing a death in
community
• Practice at writing:
– DNACPR
– Death certification
– Controlled drug prescription
• Safe use of opioids
• Any questions, comments, suggestions?