AMSA EOL Curriculum Framework ¹

I. Palliative Medicine

• Definition of palliative care (reference to the World Health Organization's definitions, origins and history of palliative care (PC), distinctions between palliative medicine and other medical disciplines, etc.)
• List of clinical components of PC (i.e., pain and symptom management, psychosocial support, etc.)
• Developing goals of care at the end of life
• Indications and benefits of PC
• Integrating palliative care as a continuum of care (e.g., making transition from acute care to palliative care)
• Role of hospice and hospice philosophy (history of movement, political and economic aspects, etc.)

II. Pain (e.g., as distinct from suffering and psychosocial distress)

• Epidemiology of pain and significance (i.e., public health view on pain at the end of life (EOL) for patients and populations)
• Barriers to adequate pain management (professional, political, or economic, i.e., attitudes toward opioids, addiction, restrictive regulations, inadequate knowledge on the part of physicians, etc.)
• Neurobiology of pain (i.e., pathophysiology of pain)
• Pain characteristics (i.e., frequency, intensity, site, quality, triggers, acute/chronic, etc.)
• Disease-specific pain syndromes (i.e., cancer- and AIDS-related pain syndromes, etc.)
• Pain-related history and physical exam (i.e., focused H&P to evaluate pain)
• Complementary therapy history (e.g., elucidate patient's use of complementary therapies for pain, such as acupuncture)
• Diagnostic assessment of pain (i.e., ability to formulate differential diagnosis re: etiology/sources of pain, etc.)
• Non-opioid pharmacologic management of pain (i.e., use of non-opioids, etc.)
• Use of opioids (i.e., World Health Organization's analgesic ladder, tolerance, dependence, addiction, therapies, drug conversions, route of administration, dosing, etc.)
• Non-pharmacologic management of pain (i.e., surgery, physical therapy, etc.)
• Efficacy of pain management (and ability to assess and revise treatment plan, i.e., ability to adjust opioids due to side effects).

III. Neuropsychologic Symptoms (i.e., agitation, depression, delirium, dementia, and other mental status changes, as well as psychological distress)

• Epidemiology and significance (i.e., prevalence of depression at EOL)
• Neurobiology of symptoms (i.e., agitation, depression, delirium, dementia, etc.)
• Symptoms as complications of therapy (i.e., changes in mental status, i.e., sedation from opioids, etc.)
• Disease-specific neuropsychologic symptoms (i.e., influence of underlying disease on mental status, personality changes from frontal-lobe tumor or AIDS-related dementia, etc.)
• Neuropsychologic symptom history and physical exam (i.e., mental status and directed physical exam, etc.)
• Complementary therapy history (e.g., patients' use of agents for depression, i.e., St. John's Wort, etc.)
• Diagnostic assessment of neuropsychologic syndromes (ability to formulate differential diagnosis using Diagnostic and Statistical Manual-IV [DSM IV])
• Counseling/psychotherapeutics
• Pharmacologic management (i.e., treatment of depression with tricyclics and selective serotonin reuptake inhibitors (SSRIs), use of psychostimulants with opioids, etc.)
• Other management strategies (i.e., acupuncture, complementary therapies, etc.)
• Efficacy of neuropsychologic management (and ability to assess and revise treatment plan, i.e., adjust from one antidepressant class to another due to inefficacy)

IV. Other Symptoms (i.e., dyspnea, nausea/vomiting, constipation, diarrhea, pruritus, etc.)

• Epidemiology and its significance
• Pathophysiology of non-pain symptoms (i.e., pruritus in hepatobiliary disease, etc.)
• Disease-specific syndromes (i.e., AIDS-related diarrhea, wasting, and weight loss in cancer, dyspnea in advanced lung disease, etc.)
• Symptoms as complications of therapy (i.e., constipation from opioids, paresthesias from chemotherapy, etc.)
• Symptom history and physical exam (i.e., focused H&P to evaluate other symptoms)
• Complementary therapy history (e.g., elucidate patient's use of complementary therapies for other symptoms)
• Diagnostic assessment of non-pain syndromes (ability to formulate differential diagnosis regarding etiology/sources of other symptoms)
• Pharmacologic management (i.e., laxatives for constipation, bronchodilators for respiratory compromise, etc.)
• Non-pharmacologic management (i.e., enemas for constipation, use of oxygen, physical therapy, etc.)
• Efficacy of pain management (and ability to assess and revise treatment plan, i.e., adjust therapies for desired effect)

V. Ethics and the Law

• Professional obligation to dying patients and families (i.e., principle of non-abandonment, commitment to clinical competence, etc.)
• Professional self-reflection regarding attitudes, beliefs, and experiences with death, dying, and bereavement.
• Analyzing ethical issues at the EOL (i.e., instruction in moral problem solving at EOL)
• Awareness of ethics committee and other institutional resources (e.g., awareness of committee role and function and guidance options for ethical dilemmas)
• Clinical capacity determinations and the legal concept of competence
• Truth-telling (e.g., ethical norms with respect to providing information regarding diagnosis, prognosis, and the therapeutic exceptions)
• Legal and ethical basis of informed consent/informed refusal process
• Legal and ethical basis of do not resuscitate/resuscitation issues
• Surrogate decision making and advance directives (i.e., decisions made by others on patient's behalf, role of living wills, health care proxies as advance directives, etc.)
• Withholding/withdrawing life-sustaining treatments, including artificial nutrition and hydration (ANH) (i.e., ethical and legal basis, legal precedent, etc.)
• Definition of physician-assisted suicide and voluntary active euthanasia (VAE) within moral continuum of EOL decisions (e.g., distinction between withholding/withdrawing life-sustaining treatments versus physician-assisted suicide and voluntary assisted euthanasia)
• Principle of double effect (e.g., ethical justification for opioid use when goal is relief of suffering, not hastening death)
• Futility (e.g., prevailing definitions regarding medical futility and strategies regarding resolution of futility disputes)
• Definition of brain death (e.g., physiologic basis, reasonable accommodations for religious objections under New York State law)
• Organ transplantation (i.e., laws and applications)
• Pronouncing death
• Autopsy requests
• Procedures on newly deceased (i.e., intubation, pericardiocentesis, and issues of surrogate consent, etc.)
• Death certification
• Public policy dimensions of end-of-life care (i.e., changes in law regarding physician-assisted suicide, Medicare hospice benefits, etc.)

VI. Patient/Family/Nonclinical Caregiver Perspectives of End-of-life Care

• Values history: spiritual-religious-cultural-other
• Psychosocial support needs at the EOL
• Loss of bodily functions
• Suffering (e.g., distinction between pain and suffering)
• Perceived powerlessness/loss of control/sense of dignity
• Burden of illness on patient/family/intimates
• Fear of abandonment
• Suicidality
• Caregiver and family dynamics and their influence on care
• Social-work interventions
• Community resources and social support (e.g., societal context of illness)
• Bereavement process and therapeutic interventions for survivors

VII. Clinical Communication Skills

• Understanding the experience of dying
• Respect for and knowledge of differing values, cultures, and beliefs
• Instruction in empathic interviewing skills
• Eliciting relevant narrative and clinical information in the clinician-patient encounter
• Ability to empathize with patients and their intimates
• Ability to work and communicate with an interdisciplinary care team
• The following specific communication skills with patient and families/intimates:
  1. Breaking bad news
  2. Informed consent/refusal
  3. Withdrawing/withholding life-sustaining treatments (i.e., having a do-not-resuscitate conversation with the patient, etc.)
  4. Advance directives (i.e., designation of health care agent by competent patient, etc.)
• H. The following specific communication skills with surrogates:
  1. Breaking bad news
  2. Informed consent/refusal
  3. Withdrawing/withholding life-sustaining treatments (i.e., do-not-resuscitate conversation with surrogate, etc.)
  4. Advance directives (i.e., working with health care proxy or interpreting living will once patient has lost capacity, etc.)
• Communicating and negotiating goals of care to patients and intimates
• Conflict resolution/negotiation skills (i.e., address and resolve conflicts regarding EOL care, etc.)
• Communicating with patients and intimates as death approaches (e.g., for the imminently dying)
• Notification of patient's death

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1 SA Meekin, JE Klein, et al. Development of a Palliative Education Assessment Tool for Medical Student Education. Academic Medicine (2000) 75: 986-992.