Distance Learning

This module provides background for the EPEC curriculum. It presents a profile of how people currently die in the United States and contrasts this with data about the way they would like to die. In doing so, it highlights how the current system fails to meet the expectations and needs of our patients and families who are living with advanced life-threatening illness.

A broad legal consensus has developed around issues of end-of-life care in the United States. This module discusses the clear and consistent legal principles directing treatment limitation, decision-making for patients who lack capacity and the use of opioids, as well as the legal aspects of the more controversial issues of physician-assisted suicide and futility.

Negotiating and determining the goals of care are essential issues for good palliative care. There are many possible goals of care, from prevention, to cure, to prolongation of life, to achieving a good death. No one goal is inherently more valid than another, and multiple goals may apply simultaneously.

Patient assessment in end-of-life care focuses on the relief of suffering. Suffering can be conceptualized as having physical, psychological, social and spiritual components. Consequently, assessment must include all of these aspects of a patient's condition and experience. A standard assessment should include disease history, physical symptoms, psychological symptoms, decision-making capacity, information sharing, social circumstances, spiritual needs, practical needs and anticipatory planning for death.

Advance care planning is about future medical care in case of being unable to make decisions. It should be a routine matter. It is a stepwise process that can be flexibly integrated into encounters with the physician or other care team members. Steps include introduction of the topic, structured discussions covering potential scenarios, documentation of preferences, periodic review and update and application of the directives when needed.

Communicating bad news is an essential skill for physicians. This module presents a six-step approach to communicating bad news. The steps include getting started, finding out what the patient knows, finding out how much the patient wants to know, sharing information, responding to feelings and planning/follow-up. Approaches for handling the family who says "don't tell" the patient, for using a translator and for communicating prognosis are also discussed.

Pain management is one of the most prominent and important symptom control skills that physicians possess. It requires a sophisticated knowledge of pathophysiology, pharmacology and therapeutics. There are three pain management modules in our program: analgesic/opioid dosing, equianalgesic dosing and managing specific pains.

Many symptoms are commonly encountered in patients with advanced illness. This module discusses the assessment and management of breathlessness, nausea and vomiting, constipation, diarrhea, loss of appetite/weight loss, edema, skin ulcers, insomnia and fatigue. Each one can both be debilitating and prevent the patient and family from either continuing their lives or completing life closure.

Physician-assisted suicide is the act by a physician of assisting a patient to commit suicide. Most physicians have received one or more requests to help a patient end their life prematurely. This module focuses on the skills that the physician can use to respond compassionately and with confidence, not by using ethical arguments but by using solid clinical skills.

Sudden illness, particularly when it is severe and unexpected and has an uncertain prognosis, challenges everyone. Structured communication is especially important and goals for care may need to change rapidly. Sociocultural differences may need rapid and sensitive appreciation to keep urgent care consistent with the patient's values.

Anxiety, confusion (part of delirium) and depression are three common and serious symptoms that occur in patients nearing the end of their lives. All three are under-recognized and undertreated. As approaches to their assessment and management are widely known, all three symptoms can be pursued by any physician.

The last hours of living are important not only for the comfort of the patient, but for all who are bereaved by, or simply witness, the death. Normal death is explained in this module, as are the key tasks that need to be accomplished before, at and after the death.

The withholding and withdrawing of life-sustaining therapies is ethical and medically appropriate in some circumstances. Physicians need to develop facility with general aspects of the subject, as well as specific skills and approaches. In this module, general aspects are discussed first. Then, three areas where this general knowledge frequently needs to be applied are covered: cessation of artificial nutrition/hydration, ventilator withdrawal and resuscitation.

Clear and unequivocal situations of medical futility are rare. More often than not the issue is conflict resolution. The physician may be pursuing unrealistic or unwanted plans. There may be difficulty for the proxy to perform his or her role. There may be misunderstandings over prognosis. There may be personal factors such as distrust or guilt, or there may be differences in values. Understanding the nature of the conflict may allow ready resolution. For intractable difficulties, a fair process for conflict resolution is recommended.