Educating Future Physicians for Palliative/End of Life Care:

EFPPEC

Paul Daeninck MD MSc FRCPC

Louise Hanvey BN MHA

for the EFFPEC project team

TopicsNeed for Palliative Care

EFPPEC overview

Progress

Future work

What do Patients & Families Want?

CompetenceCompassionPain and symptom managementClear decision makingPreparation for deathAffirmation of the whole person

Steinhauser KE et al. Ann Intern Med 2000;132:825-32

A Good Death:Patient Perspectives

5 dimensions of a good deathPain/symptom managementAvoiding prolongation of dyingAchieving a sense of controlRelieving burden on othersStrengthening relationships with

loved onesSinger PA et al JAMA 1999;281:163-8

End of Life Wishes: Seriously Ill Pts & Families

Questionnaire of patients and families

N=440/160, cancer and chronic diseasesTrust and confidence in the doctors looking after you

Not to be kept alive on life support when there is little hope for a meaningful recovery

Information about your disease communicated to you by your doctor in an honest manner

To complete things and prepare for life’s end

CMAJ 2006:174; DOI:10.1503/cmaj050626

Growing needs“Trends suggest that by 2010 cancer will be the leading cause of death in Canada”

Canadian Cancer Society

2004“By 2016, > 20% of population

will be 65 years or older”

Health Canada 2000

Canadians Expect It !

“Quality End-of-life Care: The Right of Every Canadian”

Canadian Senate Report 2000/05

Social responsibility of medical schools

“In some respects,

this century’s scientific and medical advances have made living easier and dying harder”

“Approaching Death”-The Institute of Medicine

How Well Are We Preparing Our New

Physicians?

Palliative Care in Medical Schools

None: 3

Mandatory rotation: 2

Elective only: 11

Less than 5% (0%-15%) of students participate

Oneschuk D, et al. J Pall Care. 2004;20:32-37

n=16, 2001

“Integrated” in other sessions: 6

Independent program: 6

Supervised patient encounters: 4

Mean # of hours: 11 (3-22)

Multidisciplinary faculty: 3

Oneschuk D, et al. J Pall Care. 2004;20:32-37

n=16, 2001

Palliative Care in Medical Schools

Exposure Year # of Med Schools

One 8 (50%)

Two 12 (75%)

Three 6 (38%)

Four 5 (31%)

Palliative Care in Medical Schools

Oneschuk D, et al. J Pall Care. 2004;20:32-37

What do Medical Students Want?

83% of students favoured ↑ pall. care educationOneschuk et al. J Palliat Med 2001

Exit surveys by AAMC/AFMC: medical students feel unprepared in the areas of palliative & EOL care

Direct or indirect experience with terminal illness increased their request for more palliative care

Oneschuk et al. J Palliat Med 2002;5:353-361

All Specialties Provide Palliative Care

All physicians during the course of their professional lives will be involved in caring for a patient with an incurable illnessPalliative care not just “at the end”

Palliative Medicine Training For Family Medicine Residents

Oneschuk D, Bruera E. Pall Med 1998

Mandatory rotation in palliative care? 5/16

Median length of rotation 2 wks

Elective time in palliative care for family medicine residents

16/16

Median length of rotation 3 1/2 wks

Median number of residents participating

10%

Specific faculty positions for palliative medicine

9/16

Palliative Care: Not Just About Dying & Death

What can Palliative Care Offer?

Interdisciplinary Collaboration

Self-awareness / Reflection

Spiritual & Psychosocial Care

Experience of Suffering

Ethics

Complementary & Alternative Medicine

Challenge: Integrate, not usurp

A curriculum that is already full

Map out opportunities for integration

Block SD et al.

J Gen Int Med. 1998;13:768-73

Summary Messages

Patients need & want better EOL care

Students & residents need & want better EOL skills

Role models needed

Experiential learning opportunities

LH

Project Outline

Project Overall Goal

By the year 2008, all under-graduate medical students and the residents at Canada’s 17 Medical Schools will receive effective training in palliative and end-of-life care and will graduate with competencies in these areas

EFPPEC PartnersAssociation of Faculties of Medicine Canada

(AFMC) principal partner/CHPCA co-partner

Health Canada funding & close involvement of Canadian Strategy on Palliative/End of Life Care Working Group on Formal Caregiver Education

Office is located at CHPCA in Ottawa

EFPPEC Project Team

Project Manager:

Louise Hanvey

Physician Leader:

Larry Librach

Administrative Assistant:

Jennifer Kavanagh

EFPPEC Management Committee

Alan Neville (Chair) - McMaster UniversityPaul Daeninck - U of ManitobaDoreen Oneschuk - U of AlbertaHubert Marcoux – Université LavalRobert Wadel - U of CalgaryMaryse Bouvette - CASNSue Maskill - AFMCSharon Baxter - CHPCA

EFPPEC Partners Professional Partnerships

CASNCanadian Ass’n of Faculties of PharmacyCAPPECASW

Professional Resource GroupsCSPCPRCPSC/CFPCMCC

PhilosophyBuild on present state in medical

schools by forming/facilitating local teams

Identify common competencies in EOLC and examine to those competencies

Assist in the development of curricula and clinical experiences

Evaluation is a key component

EFPPEC Objectives

Develop an interprofessional team (from various disciplines/specialties) at each university to identify gaps/opportunities related to palliative and EOLC at their university

Develop a strategy to address the gaps and implement the strategy

Support development of consensus-based palliative and EOLC common competencies for undergraduates in medicine and for postgraduate trainees in key clinical specialties

EFPPEC Objectives

Facilitate introduction of curriculum based on common competencies for all undergraduate & clinical postgraduate trainees at each medical school

Empower faculty from various specialties to become palliative and EOLC mentors/role models

EFPPEC Objectives

Facilitate the introduction of palliative and EOLC questions in licensing/certification exams

Develop network of educators

Develop a resource of programs

EFPPEC Objectives

“Top down, bottom up”approach

Top Down Approach

All 17 deans in agreement

Certification colleges in agreement

accreditation of residency programs with a component of EOLC

AFMC will accredit medical schools with EOLC as component

Bottom Up Approach

National input and consensus

Local team formation

Interdisciplinary focus

Identification of local champions

Changes at the local university level

Assist in faculty development

Common Competencies

Competencies developed based on those of the Canadian Strategy on Palliative/End of Life Care Working Group on Formal Caregiver Education

1: Address & Manage Pain & Symptoms

2: Address Psychosocial & Spiritual Needs

3: Address End-of-life Decisions & Planning using Bioethical & Legal

Frameworks

5: Collaborate as a Member of an Interdisciplinary Team

6: Attend to Suffering

4: Communicate Effectively with Patients, Families, & Other Caregivers

Progress: Where are

we at?

Local TeamsTeam leader identified at each med schoolAll but 3 medical schools activeTeam leaders form interdisciplinary

stakeholder teams to:Familiarize them with the goals of EFFPECInventory their local curricula in EOLCBuild consensus around the competencies

Local TeamsProject team to obtain relevant info from

professional resources with feed back to local teams

Local teams to share info with others across Canada, e.g. effective programs, innovations

Local teams to enhance and deliver local EOLC curricula

Video Conferences

Two so far

Successful in getting people to share their successes and challenges

Facilitates communication

Not all teams involved as yet

University of MB TeamLocal Leader: Dr. Marcelo Garcia

Team members identified

Local curriculum reviewed, gaps identified

Working with University to integrate

Presently have approx. 15 contact hrs

Related areas may double contact

Experiential learning electives possible

Learning CommonsDeveloped with the help of the Pallium

ProjectWebsite for sharing information and

educational programsUnique features

ForumSearchableNotification of subscribers

CommunicationsDeveloping communication strategy:

Logo and branding

Website (www.efppec.ca)Newsletters & other forms of regular

communications with local teamsSymposiaConference presentations & boothsVisits to university faculties

EvaluationInstrumental evaluation

What has been accomplished so far at each of the identified nodal points

Quantitative & qualitative

Appropriate & realistic outcomes

Done in collaboration with Wilson Centre in Toronto

Final report to include outcomes

Faculty Development

Assess needs for faculty development and facilitate development of these resources

Hope to use local expertise

Challenging for several groups

Palliative care not yet full academic status

2006 SymposiumHeld in London ON in May

Meeting of the AFMC/CAME/CFPC/MCC/RCPSC

Over 80 attendees

Excellent exchange of ideas

Interprofessional presence

Priorities:

Faculty development

2007 SymposiumPlanning underway

Likely in Fall, ? CHPCA Annual Meeting

Interprofessional meeting

Review of local team progress

Faculty development

Sustainability

Undergraduate Competencies

Project team worked with Ontario and Quebec groups

A draft curriculum in place

Seeking consensus across country

Detailed enabling objectives

May add evaluation suggestions

Family Medicine Competencies

Worked with CFPC to develop postgraduate training competencies

Approved by CFPC, linked to Four principles and CanMEDS

Will be incorporated into the Red Book, guidelines for program teaching

Specialty Competencies

Royal College Specialty Committees asked to develop competencies

Internal Medicine, Critical Care finished first draft

Surgery, Psychiatry, Pediatrics, Oncology currently in process

Meeting with RCPS Education Office

Looking Ahead

What’s Next?Royal College specialty competenciesLearning commons Developing palliative / EOLC questions

in licensing / certification exams Working with accreditorsInterprofessional project fundingIndividual schoolsSustainability

Summary

An ambitious 4 year project to introduce effective teaching in end of life care and produce physicians who are competent in this area

Questions?