Professional Documents
Culture Documents
Final Curriculum Toolkit
Final Curriculum Toolkit
THET DFID
Kaly Snell, Mhoira Leng, Julia Downing, Alan Barnard, Scott Murray,
Liz Grant
1
Preface
This toolkit is prepared for a wide readership, from health sciences education
specialists to clinical teachers at universities and in hospitals or community-based
services. It suggests a framework of educational and assessment practice, including
many practical examples. These examples are not exhaustive, and should be
adapted to local conditions and the availability of resources.
2
A Palliative care curriculum toolkit: A practical guide to integrating palliative care
into health professional education
Contents
References 46
3
A Palliative care curriculum toolkit: A practical guide to integrating palliative care
into health professional education
Section 1
Background
Introduction
The integration of palliative care in education programmes is a crucial component of
increasing access to impeccable, comprehensive palliative care for all1,2. A number
of excellent resources already exist to provide palliative care education and training
for the different cadres of health worker across both pre-service and in-service
levels. Several good examples of curriculum design and palliative care competency
frameworks are available, including the European Association of Palliative Care
(EAPC) recommendations 3 , the African Palliative Care Association (APCA)
competency framework 4 and the Palliative Care Curriculum for You (PCC4U)
resources5. Innovative programmes have been developed in countries in the sub-
Saharan African region such as Kenya, Uganda and South Africa which include
postgraduate stand-alone palliative care courses as well as the integration of
palliative care into the curricula of medicine and nursing. APCA continue to build an
emerging culture of palliative care training and service development across the
continent.
4
- That the palliative care approach guides all learners to understand the
importance of comprehensive and holistic care which is patient and family
centred;
- The opportunity for palliative care education and training to be integrated
into curricula within many existing subject areas and cross cutting curricular
themes;
- The importance of shared training for all members of the inter-disciplinary
health, social and spiritual care teams.
Rationale
Over 20 million people require palliative care per year. The highest proportion (78%)
of adults needing palliative care reside in low or middle-income countries6. In the
African region, the escalation of non-communicable diseases in addition to the
burden of HIV/AIDS, other communicable diseases and multi morbidity, makes the
delivery of palliative care at all levels of the health service a priority. Palliative care is
essential to health care, as endorsed by the United Nations World Health Assembly,
Worldwide Palliative Care Association and Human Rights Watch. The 2002 Cape
Town Declaration advocated for palliative care to be incorporated into all national
health care strategies recognising that the relief of pain is a human right7. In May
2014 the World Health Assembly (WHA) passed a seminal resolution recognising
palliative care as a requisite component of health services worldwide8. Integration of
palliative care into basic and continuing education training for health professionals
was identified as a critical factor for the successful implementation of this resolution
worldwide.
Existing palliative care competency frameworks and educational tools have been
signposted, for adaptation into local context. Please acknowledge and attribute the
original documents. There is no unique way of integrating palliative care into an
education setting; hence this toolkit provides innovative ideas and methods to
integrate palliative care in different contexts.
5
Underpinning philosophy
Education in palliative care should produce competent practitioners, leaders and
local ‘champions’ who are motivated to integrate palliative care into their practice
and improve access for all9. In the ethos of values based learning, palliative care
values must be seen to lie ‘not only at the heart of the educational content, the
“what” of education, but also at the heart of the educational process, the “how”, the
way in which education is conducted.’10 Therefore underpinning this document and
the development of curricula for palliative care are several key values:
• The philosophy and practice of palliative care based upon the WHO
definition (Figure 1)11 with an emphasis on: quality of life for the patient and
their family; providing care from diagnosis through to death and into
bereavement, across a range of conditions and across the ages. Care should
be provided in the setting most appropriate for the patient and their family.
Figure 1
WHO Definition of Palliative Care
Palliative care is an approach that improves the quality of life of patients and their families facing the
problems associated with life-threatening illness, through the prevention and relief of suffering by means
of early identification and impeccable assessment and treatment of pain and other problems, physical,
psychosocial and spiritual. Palliative care:
- Provides relief from pain and other distressing symptoms;
- Affirms life and regards dying as a normal process;
- Intends neither to hasten nor postpone death;
- Integrates the psychological and spiritual aspects of patient care;
- Offers a support system to help patients live as actively as possible until death;
- Offers a support system to help the family cope during the patient’s illness and in their own
bereavement;
- Uses a team approach to address the needs of patients and their families, including bereavement
counselling if indicated;
- Will enhance quality of life, and may also positively influence the course of illness;
- Is applicable early in the course of illness, in conjunction with other therapies that are intended to
prolong life, such as chemotherapy or radiation therapy, and includes those investigations needed to
better understand and manage distressing clinical complications.
The WHO also highlights the need for palliative care for both adults and children, stating:
Palliative care for children is the active total care of the child’s body, mind and spirit, and also involves
giving support to the family. It begins when illness is diagnosed, and continues regardless of whether a
child receives treatment directed at the disease. Health providers must evaluate and alleviate a child’s
physical, psychological and social distress. Effective palliative care requires a broad multi-disciplinary
approach that includes the family and makes use of available community resources; it can be successfully
implemented even if resources are limited. It can be provided in tertiary care facilities, in community
health centres, and even in children’s homes.
6
• Inter-professional and inter-disciplinary education. Teamwork is central to
the practice of palliative care; thus, whilst recognising the importance of
specific knowledge and skills for different professions, the opportunity for
learning together as an inter-professional group is important where possible.
Students should also be exposed to inter-professional facilitation, and inter-
professional modeling of teamwork.
• The need for skilled and experienced educators. It is important that those
facilitating training are experts in the field that they are teaching. Palliative
care expertise is important to provide technical oversight and input to
palliative care education, but specific aspects of a course may be taught by
subject experts e.g. pain management and spiritual care. Educational
expertise is also required to oversee the programme and draw everything
together.
It is important to note that the tiers are a guide and the assumption is made that
care providers will build upon their competencies as they become more experienced
and specialised. However, they may be of use for those planning health services as
they decide the level of knowledge, skill and attitude that their staff will need to
7
possess in order for them to work at the particular service level.
8
3. Psychosocial and spiritual
4. Ethical and legal
5. Communication skills
6. Teamwork and professionalism
Section 2: Toolkit
- Curricular themes. A set of learning objectives that are unique and unifying
are spread out throughout the curriculum and influence other sets of
learning. This can be in a linear fashion (thread) or designed to add width and
depth with each curriculum encounter (spiral) where there is explicit
understanding of the expectations at each stage. These spirals may in turn
contain uniting themes. Examples include:
o Communication may be a spiral theme that initially covers basic skills
in communication and clinical interactions. Skills relating to breaking
bad news and handling collusion may then be added at an
appropriate point in that course.
o Professionalism is now a theme in many curricula and provides a
valuable opportunity to strengthen the competencies relevant to
palliative care such as self-awareness, avoiding burnout, negotiating
with colleagues or working in a multi professional team.
9
o Knowledge based delivery via lectures of directed learning in year 1 or
2 followed by 1 week clinical modelling though placement in year 3 or
4.
o Teaching blocks may be contained within existing courses such as
oncology or HIV care.
Section 2b: Carrying out a curriculum review in your setting, including an example
from Zambia
Consultation of your own curriculum may reveal palliative care topics and philosophy
diffusely ‘hidden’ throughout. The Palliative Education Assessment Tool18 (PEAT) is
an innovative self-assessment tool designed to facilitate curricular mapping of
palliative education in medical undergraduate curricula. The tool is recommended
and adapted by the European Association for Palliative Care (EAPC) steering group
on Medical Education and Training3. The PEAT process identifies palliative care
content in an existing education programme and compares it with an established
palliative care curriculum such as the APCA core curriculum19. This process can be
applied to reviewing curricula in other palliative (and non-palliative) education
settings. In order to meet the needs of different health care systems and the needs
of your students, the general approach to curriculum planning (Kern 199813) should
be applied. This includes:
10
An example of how to evaluate and integrate palliative care in to a curriculum –
University of Zambia, School of Medicine (UNZA SoM), medical undergraduate
curriculum review
This example demonstrates the use of the PEAT tool in identifying strengths and
areas to develop in relation to palliative care education. The process involves:
Step 1 Identify syllabus to benchmark against (this example uses the EAPC
recommendations for undergraduate medical education3) (see ‘Palliative care
domain topics’ in table below)
Step 2 Identify ‘hidden’ palliative care topics within the existing curriculum/modules
(see ‘Current (existing curriculum mapping’) in table below)
Step 3 Suggest potential sites for unplaced topics (or potential changes to existing
sites) (See ‘Suggested place/year for teaching’ in table below)
Step 4 Build in relevant learning objectives (developed as per local
context/competencies required) (See ‘learning objectives in table below)
11
UNZA curriculum review – strengthening palliative care teaching
Palliative care domain topics (EAPC core syllabus 3) Current (existing) Suggested Learning Objectives
curriculum mapping place/year for ‘By the end of MB chB curriculum, graduates should
teaching be able to…’
b) Pain Management
-Definitions and concept of pain Physiology, 3rd year – To further develop • Revisit concept of total pain
Pain management during Internal • Describe common mechanisms of pain/pain
12
-The concept of total pain medicine 5th year syndromes
and 6th year • Describe how to carry out a pain assessment
-Anatomy, pathophysiology Physiology, 3rd year - • Be aware of pharmacological and non-
Physiology of nerves pharmacological management of pain
-Mechanisms of nociceptive pain • Explain the principles of good prescribing in
Neurological sciences, a palliative care setting
-Mechanisms of neuropathic pain 4th year - Somatic • Describe the three steps of the analgesic
sensations ladder (giving examples)
-Recognition of chronic pain features • Explain the use of adjuvant drugs
Neurological sciences, • Explain the role of morphine in pain control
-Principles of pharmacological treatment: 4th year - Drugs used • Describe the side effects of morphine and
- Importance of achieving ‘steady state’ in the management of how to manage them
- Using the simplest available route of pain • Manage breakthrough pain
administration • Calculate and adjust the dose of morphine
- Role of titration
• Be able to identify and treat morphine
- Necessity to prescribe ‘rescue’ medication
overdose
- The role of ‘equianalgesic’ doses
• State the legal requirements for prescribing
- The role of opioid rotation
morphine
-Pharmacokinetics and dynamics of opioids, non-
opioids and adjuvant analgesics
13
• Interventional procedures (anaesthetic and
neurosurgical)
• Nursing interventions
• Counselling and psychotherapy
• Social interventions
• Physiotherapy
• Complementary therapy
14
-Management of bowel obstruction
-Pulmonary symptoms:
• Dyspnoea
o Pathophysiology
o Relevant pharmacology (opioids,
anxiolytics, steroids)
o Principles of oxygen therapy
o How to deal with ‘death rattle’
• Cough
15
-Dermatological symptoms:
• Wound breakdown
• Lymphoedema
• Itch
16
6th and 7th year
-Impact on patient and family of loss of
independence, role, appearance, sexuality and
perceived self-worth
-Family dynamics
-Coping strategies
-Anticipatory mourning
17
-Discussion and decision making at the end of life, Community medicine, Revisit during • To be aware of palliative care as a human rights
particularly the abatement, withholding and 5th year – healthcare internal medicine issue
withdrawal of treatment ethics 6th year • Be able to use ethical principles to help make
decisions about patient care in a palliative
-The ways of negotiating and placing ‘do not setting. Including:
attempt resuscitation’ (DNACPR OR DNR) o Withholding and withdrawing
treatment
-Exploration of proxy decision-making, advance care o Artificial hydration at the end of life
planning o Identifying and responding to issues
of Collusion
-Distinction between palliative care and euthanasia Re-iterate during • Be aware of the distinction between euthanasia
introductory 5th and palliative care
-Distinction between euthanasia and physician year session
assisted suicide
5 Communication
18
-Verbal vs non- verbal communication Internal medicine, 4th Revisit during • An ability to communicate effectively with
year– verbal and non- Internal medicine patients and their families in a clinical setting
-Special situations of communication: verbal communication 6th and 7th years especially when breaking bad news and respond
• Patient’ s information, prognosis appropriately to reactions of patients and
• Decision making Community medicine, families
• Conflict and conflict resolution 5th year -
• Talking with relatives communication skills
19
Section 2c: Teaching and Learning methods with worked examples
This is an illustrated list of teaching and learning methods suitable for various
contexts and for any level of learner in all professions. These examples may be used
as they are, or adapted and made relevant to the local context. However, the
methods are not exclusive to these highlighted topic areas and may be widely used
across the domains.
Self-directed Example 1
Provide a set of learning outcomes.
reading OR Topic
• Ask learners to assess their ownTeamwork in Palliative Care
learning needs against the Learning Objective
Demonstrates insight into the role of the
objectives (with facilitation if
required) interdisciplinary team.
• Suggest some text books, Assessment criteria
websites and library access Identifies roles of various members in the care
• Encourage learner to discover of the patient and demonstrates awareness of
the sources, read around the referral system
topic and meet their own Task
learning needs Write a short case report of a palliative care
clinical scenario that you recently experienced
Notes: (300-500 words). Describe all the team
• High order learning members involved in the care. Discuss the role
• Postgrad programmes of each member and the interaction of the
• Senior medical or nursing team members.
students (UG) Resources (just a start)
• Senior students in other health EAPC education resources
sciences (Pharmacology, speech http://www.eapcnet.eu/Themes/Education/Pu
and language, physiotherapy, blicationsdocuments.aspx
occupational therapy etc)
Example 2
Topic
Advocacy in Palliative Care
Learning Objective
20
METHOD DESCRIPTION EXAMPLE
Identify opportunities for PC advocacy at
community level and develop a plan for a
community event to promote a palliative care
message
Assessment criteria
Opportunities listed with a written plan for the
execution of a community event
Report of the event with SWOT analysis
Task
Plan and conduct a community awareness
event in PC
Resources (Just a start)
APCA Successful Advocacy for Palliative Care: A
Toolkit
http://www.africanpalliativecare.org/images/st
ories/pdf/toolkit.pdf
Example 3
Topic
Management of Nausea and Vomiting in
Palliative Care
Learning Objective
Classify the causes of nausea and vomiting
Write a management plan for any patient with
nausea and vomiting
Justify antiemetic choices based on
pathophysiological causes
Assessment criteria
Evidence of knowledge of pathophysiology of
emesis
Application of this to a clinical scenario
Task
Write a treatment guideline for use by a junior
doctor in the treatment of nausea and vomiting
in palliative care
Resources (Just a start)
Oxford Textbook of Palliative Medicine
APCA Handbook of Palliative Care in Africa
http://www.africanpalliativecare.org/images/st
ories/pdf/Handbook.pdf
Palliative Medicine: Pain and Symptom Control
in the cancer and/or AIDS patient in Uganda
and other African countries. HAU.
21
METHOD DESCRIPTION EXAMPLE
http://www.hospiceafrica.or.ug/index.php/pub
lications/blue-book/send/3-blue-book/3-blue-
book-english-vrsion
Example 4
Topic
Public advocacy for appropriate attitudes to life
threatening illness
Learning Objective
Understand the public understanding of
palliative care
Assessment criteria
Contribute to the discussion in public
Task
Read the attached article
http://www.theguardian.com/commentisfree/
2015/jul/25/oliver-sacks-who-has-taught-us-so-
much-now-teaches-us-the-art-of-
dying?CMP=fb_gu
Find another article in the lay press about life
threatening illness and compare the two
articles
Write a letter to Oliver Sacks saying how this
piece of writing will help you in practice.
Submit this letter to your local newspaper for
publication alongside the above insert.
Resources
Google
22
METHOD DESCRIPTION EXAMPLE
11. Providing spiritual care at the end of life
12. Management of the dying phase
13. Legal aspects of palliative care
23
METHOD DESCRIPTION EXAMPLE
the use of drugs at the end of therapeutics ward round using a starter
life (or in palliative care in palliative care formulary.
general • The patient is asked about goals of
• Patient must be prepared and treatment and use of risk management
give informed consent to the medication like statins.
discussion. • The patient contributes to the
discussion regarding side effects etc.
• The patient’s prescription is analysed
and discussed line by line
Example 2
Focus on taking a detailed pain history
Small group bedside session. Tutor explains the
process to student/s before the session
• Tutor takes the history (using a
framework like PQRST or SOCRATES)
and each student listens with or without
taking notes
• Students can direct clarifying questions
through the tutor.
• Discussion at the bedside (if patient
agrees)
• Patient input possible
• Address total pain in the discussion
Group work for Any topic that is broad and in which Example 1
presentation and input from all is valued. The impact of a family meeting
discussion • Important to have rules of Pre-reading on value of family conferences and
(12 to 30 people) engagement how to conduct them
• Respect and confidentiality Watch a video about a family meeting
• Needs careful Possible resources include:
24
METHOD DESCRIPTION EXAMPLE
leadership/husbandry “Little Stars” (http://www.littlestars.tv)
“Life before death”
(http://www.lifebeforedeath.com)
Example 2
Identifying the palliative care patient in another
context
Before a medical/gynae/surgery teaching
round, prepare the group for the group
discussion to follow by asking them to consider
the patients’ needs for palliative care
(diagnosis, surprise question, symptom burden,
prognosis)
• Tutor attends the ward round with the
students with the consent of the consultant
in charge
• Group discussion of the ward round
• Tutor chooses one case and all discuss the
palliative care needs in detail.
Assessment
Each student to present one case and the
palliative care needs to a partner in the session
Feedback by the student
Peer assessment of fulfillment of the task on a
written rubric
If that patient were your
father/brother/grandmother/daughter, how
would you assess the presentation?
(Likert scale) 1= least well 5 = very well
25
METHOD DESCRIPTION EXAMPLE
a. Was the case correctly identified? (1-5)
b. Was the symptom burden complete? (1-
5)
c. Did the student consider the
psychosocial aspects? (1-5)
d. Was the prognosis addressed? (1-5)
e. What was the general impression of the
assessment? (1-5)
Role Play Communication skills learning Use short clinical scenarios to set up difficult
conversations between doctor and patient
Notes: • Divide the group into pairs with one taking
• Careful support required by the role of doctor and one of patient.
tutor and more than one • Explicit instruction for patient to show an
experienced tutor may be emotion e.g. anger, worry, shock
helpful in this exercise as the • Short role play 2-3 minutes
students sometimes struggle to • Responses and tutor led discussion about
contain their own issues. the activity and emotional reaction of the
• Safety and confidentiality must professional person.
be assured. • Instructions and comments about the use
• Distress protocol essential. of silence, acknowledgement, normalisation
and containment
26
METHOD DESCRIPTION EXAMPLE
Portfolio of The learning journey in all topics Topic
learning and personal development. Identification of patients in need of palliative
care
Notes: Learning Objective
• Mentorship a key success factor Identify patients in a general clinic or ward who
for this activity may need palliative care.
• Definition of portfolio is Justify the method you have used
important to be understood by Assessment criteria
the tutors, students and the Portfolio discussion with consultant. Allocate a
persons contributing to that global score out of 9
portfolio e.g. patients, patient 1. Not done
proxies, peers and others 2. Poor
• A reasonable working definition 3. Many gaps
is “ evidence of learning in a 4. Some critical areas not covered
field.” Which could include 5. Satisfactory with some areas needing
notes, commentary, exam improvement
results, case reports and 6. Satisfactory with few areas not covered
artefacts among others 7. Good with coverage of most areas
• Should be completed over at 8. Good with very few gaps
least one month, but preferable 9. Comprehensive and excellent
more even over a whole year. Task
Assemble your learning portfolio including the
tools and criteria you used and the articles and
guidelines that you found helpful
• Write one long case report of a patient
using the identification tools
• Write three short case notes
• Collect a story from a patient about
their palliative care experience
• Find an article/artifact/musical
lyric/poem/photo that contributes to
your learning and describe that learning
through the item.
• Keep a weekly diary about this portfolio
and you learning
• Write a reflective piece as the final diary
entry.
Resources
Google, Library, Imagination, a mentor
27
METHOD DESCRIPTION EXAMPLE
d. Challenging b. Direction towards resources
c. Modeling of clinical skills
d. Demonstration of self-care
e. Holding to account
Assessment is reflective journaling
Useful to encourage the mentee to take on
mentorship roles of other team members as
confidence and competence permits
Not summative
http://integratepc.org/mentorship/
Example 2
Preceptorship
Predominantly skill and practice based
• Much in common with mentorship but may
be applicable over shorter attachment and
looser commitment to the longer journey.
• Feedback a critical element, with care that
this is constructive and also in a spirit of
positive regard. Framework of appreciative
enquiry useful.
• Can be useful in skills training and tested via
OSCE or similar.
Introduction
Detailed information on assessment theory and the methods of achieving the above
can be found in the resources section of the toolkit (under ‘Resources for
assessment’ page 55)
28
Which Assessment Method to Choose?
There are various methods and all can be used within the palliative care setting,
often across topic areas. Miller (1990) (+ref) provides a useful means of mapping
these tools against the competencies required of the students. Further detail on the
assessment tools listed can be found
A 22-year-old lady has advanced heart failure secondary to rheumatic valve disease.
She is too unwell to travel from her rural home to the tertiary referral centre.
Surgical correction of the valve problem is not available in this country. She is very
29
breathless and frightened. Please describe your understanding of palliative care (2
marks) and how it might help this patient. (4 marks)
Example model answer notes: Palliative care involves care of those with an incurable
illness. It can be offered to a person, at any age, at any stage of the disease
trajectory and is followed through during bereavement (2 marks)
Palliative care focuses on improving quality of life as defined by the patient. It
involves holistic care, taking into account the physical, spiritual, psychological and
social needs of the patient within their cultural context. Palliative care involves a
multidisciplinary approach; it is patient centered and also supports family members
and those who are important to the patient. (4 marks)
Example 2: MCQ
A 66year old patient presents with symptoms and signs of a progressive bulbar palsy
on the background of being HIV positive (CD4 560, on Tenofovir and Effivirenz). It is
felt the bulbar palsy is unrelated to her HIV status. The MRI head is normal. The
diagnosis is thought to be a variant of amyotrophic lateral sclerosis (motor neurone
disease). Her main problems are with speech and swallow. Her daughter suggests
palliative care may be able to help in her management. Please indicate true or false
for the statements below (correct answers underlined):
a) Palliative care should be reserved for those in the terminal stage of an illness
T/F
b) The patient should never be told that the disease is incurable as she may lose
hope T/F
c) We should be honest with the patient and tell her there is nothing we can do
T/F
d) She may benefit from PEG feeding at some point in the future T/F
e) She does not require morphine, but may still benefit from palliative care
input T/F
Additional examples/ideas:
• Long written question: Total pain Read the following scenario and apply the
concept of “total pain” to the patient and family members involved. Discuss the
different elements of that pain and suggest a plan of action. Scenario: Mr ST is a
65-year-old man with Lung Cancer and you have been his family doctor for 12
years. He is using paracetamol 1000 mg by mouth 6 hourly and codeine 30 mg by
mouth 4 hourly. He has developed sharp 8/10 pain in his chest with breathing
and has become moderately short of breath, even at rest. His wife is with him
and is very worried about looking after him at home as she feels she will not
cope. He is also not sure whether to take further chemotherapy, as he only felt
worse after the last round of chemo. He reports that his daughters really want
him to proceed with treatment but he doesn't see the point and is inclined to
30
just take medicines for symptoms. They have had some family strife over these
decisions and now he feels isolated and that there is no point to life anymore.
• Journal entry for the learning portfolio: The palliative care approach Visit the
palliative care service in your hospital or community. Discuss the palliative care
approach with the professional nurse in the ward or clinic. Visit a high care ward
at your local hospital. Ask the professional nurses about a recent experience with
a patient who had died there. Discuss the possible role of the palliative care
approach in the high care ward with a colleague or the tutor. Write a reflective
journal entry for inclusion in a palliative care learning portfolio.
A 38 yr lady with known, inoperable, advanced renal cell carcinoma, bone and lymph
node metastases presents with drowsiness, nausea, vomiting, constipation, thirst
and polyuria. She has no other known past medical history. Please state true or
false for the following statements (correct answers underlined):
A patient is taking normal release morphine liquid 5mg four hourly for nociceptive
pain in his leg due to osteosarcoma. The morphine has had some effect, but he
continues to experience pain. Please choose the single best option from the list
below (correct answer underlined):
31
e) Slow release morphine tablet 30mg BD should be substituted for the
morphine liquid
Station 1: A patient on your ward has a great deal of pain that has not responded to
paracetamol, diclofenac or codeine. You wish to prescribe morphine. The doctor on
the ward is not happy with this. Please speak to him:
Mark
Introduces self and establishes which patient they are discussing /2
Politely enquires how they can help or what the issues are /2
Explains that, commenced and titrated appropriately for analgesia, /4
should not be a risk of addiction
Explains that morphine is used for symptom control and used/titrated /4
appropriately, should not shorten life
Explains that tolerance to analgesia not usually a problem. (Tolerance /4
to some side effects can be a useful phenomenon)
Explains there is no evidence that morphine will mask disease /4
progression. Symptoms may progress as the disease progresses
Explains that morphine can be legally prescribed for symptom control /4
in this country
General approach: (calm manner, body language, overall impression /3
of communication skills)
32
Self awareness/reflection: /3
1. Able to correctly identify own areas for improvement
(Examiner could ask: ‘anything you would do differently?’
Final Mark (30 marks) /30
Station 2: This patient is taking 5mg of morphine liquid (10mg/5ml) every four hours
and is due to go home. Please complete the prescription for his morphine on
discharge. You may use any details available in his notes (provided) (12 marks)
A student may have included a patient with palliative care needs in any of their
hospital or community attachments. The focus of the case based discussion
assessment could be around a topic on pain and symptom control. For example, a
patient with a pressure sore. Please see resources section, page 55, for link to
example generic case-based discussion proformas.
Additional examples/ideas:
33
• Journal entry for the learning portfolio: The role of the clinical pharmacist in
palliative care prescription Visit the pharmacy where strong opioid medication is
prepared and dispensed. Ask the pharmacist what their role in pain control
encompasses? Ask about barriers to pain control from the pharmacist’s point of
view. Write a reflective essay on the topic and place it in your portfolio.
• Long written question: Pain assessment and management Read the following
scenario and describe the possible mechanisms for the severe thigh pain and
inability to walk:
Kato is a 76 year old University lecturer who has carcinoma of the prostate with
bone metastases. This was diagnosed 2 years ago and he was treated with surgical
castration. He recently presented to the oncology team with bone pain and a bone
scan has shown multiple lesions in both femurs, thoracic spine and ribs. He was
commenced on diclofenac 50mg tds and oral morphine has been titrated to 10mg 4
hourly, with bisacodyl 15mg. His pain has been well controlled on this combination
for several months although he is losing weight and generally
You are requested to visit the patient as he has become increasingly drowsy and
complains of severe pain in his right thigh with inability to walk. The family had
arranged for him to be seen by a private clinic and the blood tests that they had
requested show he has significant renal impairment. He is passing very little urine
and not eating or drinking and his family wants him to have IV fluids and nutrition to
get strong again. His son who is studying in India also wants to fund him to travel
there for dialysis and consideration of renal transplant but Kato prefers to stay at
home.
34
A student could be observed doing a psychological, social or spiritual assessment of a
patient. Please see resources section, page 55, for link to example Mini-Cex
evaluation profomas.
Please describe your approach to assessing Esther, including example questions you
may include. (30 marks)
Assessment would be sensitive and at the patient’s pace, it would ideally include
(note not all questions may be asked at one time, but could be considered): (2
marks)
1. physical, social psychological and spiritual
a. Physical: questions about the dark swelling, pain (precipitating and
relieving factors, quality, radiation, site, severity, timing, effect of
treatment) and any other physical issues (7 marks)
b. Social: Explore the impact of illness on social setting and vice-versa.
Explore who gives support to Esther, whether she is depended on for
supporting anyone else (may include family tree), her practical
(cooking, cleaning, shopping) and personal (washing, dressing,
managing the bathroom, eating) activities of daily living, her home
situation (?availbility of electricity/water/transport), finances, her role
in life and how this may have changed as a result of illness and recent
event 7 marks)
c. Pyschological: What she understands by her illness/how she is
feeling/how her mood is/does she have any concerns (7 marks)
d. Spiritual: What gives meaning and value to her life/what is important
to her/what keeps her strong/has any of this changed as a result of
her illness? (7 marks)
35
b) He should be discharged home as he is dying
c) Morphine does not have a role in his management as he does not have pain
d) He may be frightened and this should be addressed in order to support him
e) The chaplain should be requested to pray with him, even if this is not what
the patient wants
Additional examples/ideas:
• Journal entry for the learning: Meaning and purpose Find a creative art
expression of pain and suffering, or write a poem or song, or paint a picture.
Show somebody. Ask them to respond and record their response for your
journal.
• Formative assessment: Place of death Find two recent articles in the literature
about “place of death”. Reflect on your own observations and personal
experience, or ask a senior colleague/peer/spiritual worker about their
experience. Write up your findings for your journal.
36
4 Ethical and legal
Please state true or false for the statements below (correct answers underlined):
a) Palliative care is an acceptable form of euthanasia T/F
b) Euthanasia and physician assisted suicide is illegal in every country in the
world T/F
c) With correct prescribing and titration, morphine can be used safely for pain
control T/F
d) Withholding medical treatment is a humane form of euthanasia T/F
e) Medical treatment should never be withheld T/F
• Long written question: Pain and palliative care as a human right Discuss the
value that the human rights approach brings to the provision of care to the most
vulnerable members of society.
• Journal entry for the learning portfolio: Advance care planning Conduct an
interview with a patient and family about advance care planning and discuss this
with a colleague. Write a reflective journal entry for inclusion in a palliative care
learning portfolio.
• OSCE station: Autonomy in a vulnerable person Read the scenario and list the
factors that should be taken into account in order to maintain the patient
autonomy (dementia/children)
• Formative assessment: The role of palliative care and desire for hastened death.
Conduct a survey among five friends about their views on end of life care and
euthanasia. Summaries the findings and discuss in your tutorial group. Tutor
mediated discussion to draw in the role of palliative car and desire for hastened
death. (Group and tutor feedback at end of discussion)
5 Communication skills
Example 1: OSCE
Station 1: Breaking bad news: Rachel is a 38-year lady admitted a week ago with
abdominal swelling and pain. She is HIV positive and known to have chronic
hepatitis B. Her alpha-fetoprotein levels are markedly raised. This and radiology (CT
and ultrasound) indicate a diagnosis of hepatocellular carcinoma. This is not
curable: there are multiple large tumours, which, therefore, cannot be surgically
resected. Chemotherapy and radiotherapy are not treatment options.
37
The nurse in charge has trained in palliative care and she is concerned that Rachel
does not understand her diagnosis. She has asked that you explain the diagnosis
and answer any questions that Rachel may have.
Mark
Greets patient and introduces self /1
Enquires about what the patient already knows/understands /4
Finds out how much the patient would like to know /4
Shares the information (giving truthful information in a sensitive /5
manner. Avoids using medical jargon where possible– but if technical
language is used, ensures the patient understands)
Responds to the patient’s feelings /3
Gives a clear plan (even if this is just to check with seniors what the /4
next step is) and information on follow-up
General approach: (manner, body language, overall impression of /4
communication skills)
Self awareness/reflection: /5
1. Able to correctly identify own areas for improvement
2. Aware of issues on how to prepare for giving bad news to a
patient or relative, for example, tells examiner:
a. they would ideally read notes/gather all information
etc before seeing patient
b. ensure they will not be disturbed (eg turn mobile
phone to silent)
c. ensure privacy where possible
d. check to see whether the patient would like a relative
with them)
e. or other relevant preparation
Example 2: Mini-cex
38
A 66 yr man returns to clinic for his CXR results. The clinical picture and imaging are
very suggestive of lung carcinoma. The next step is referral for bronchoscopy for a
biopsy and histological diagnosis. The histology later confirms squamous cell lung
cancer and he is found to have stage 4 (advanced, metastatic) disease. Please
indicate the single best answer from the following statements (correct answer
underlined):
a) He should not be given any indication that the diagnosis may be lung cancer
until the biopsy results are back
b) Questions should be answered with open detail to all patients even if the
patient does not want to know
c) We should ask the family what the patient would like to know before we talk
with the patient
d) We should not share the information with the patient as it is not culturally
appropriate to discuss death and dying
e) It is helpful to check the patient’s current understanding before proceeding
to explain further information at the patient’s pace and wishes
Additional examples/ideas:
• OSCE Station: Breaking bad news Watch a one minute breaking bad news video
and write a list of things that went badly
• Journal entry for the learning portfolio: Modelling of communication skills
Observe a consultant on a ward round while interviewing a patient with palliative
care needs. Write a journal entry on the interaction and connection that
developed in that conversation. Include this in your learning portfolio
Please see resource section, page 55, for link to example 360-degree proforma
This may be used to assess a student’s professional values and attitudes. Self-
awareness can also be demonstrated.
39
Example 3: Short Answer
Additional examples/ideas:
• OSCE Station: Collegial practice and referral “Write a referral note to the
appropriate team member listing the palliative care priorities for the attention of
that colleague.
• Journal entry for the learning portfolio: Self-care Write a reflective diary entry
about your own self-care during the palliative care learning sessions. Identify an
activity that would assist you in future with balance between professional and
personal life.
• Written answer: Complaint procedure and Distress protocol Read the scenario
and identify the reasons for the distress in the family member. Respond to the
written complaint from hospital management and write a distress protocol to
improve quality of care in future.
40
Section 2e: Resources
Core Competencies,
20104
APCA: Palliative care http://www.africanpalliativecare.org/images/stories/pdf/Palliative_Care_Core_Curriculum.
pdf
core curriculum, 2012 18
EAPC: http://www.eapcnet.eu/LinkClick.aspx?fileticket=S1MI-tuIutQ%3D
Recommendations of
the EAPC for the
Development of
undergraduate
curricula in palliative
medicine at European
medical schools. EAPC
20133
competencies for
education on
paediatric palliative
care, November 2013
41
Training manuals/resources
42
Useful Resources for students and trainers
Care Handbook
43
Makerere Palliative http://www.ed.ac.uk/global-health/research/project-profiles/health-systems-
strengthening/thet/resources
• Adapted/adopted for use in Uganda, Rwanda and
Care Unit, Uganda, Zambia
Clinical Guidelines • Practical guidelines on Pain assessment and
management in adults and children, constipation,
breathlessness, mouthcare, nausea and vomiting,
wound management, delirium, malignant spinal
cord compression and care at the end of life
Children’s Palliative http://www.icpcn.org/wp-content/uploads/2013/08/Childrens-Palliative-Care-in-Africa-Full-
Text.pdf
Care in Sub-Saharan
Africa
International http://hospicecare.com/join-iahpc/
• IAHPC membership is discounted according to
association for level of income of the particular country you or
hospice and your institution is based. Membership offers free
palliative care access to full text articles from leading palliative
care journals
Links to www.jrcptb.org.uk/assessment/workplace-based-assessment
proformas/user
guides for Mini-cex,
DOPS, CBDs and
3600 appraisal
44
Other useful resources
45
References
1Sepulveda C, Marlin A, Yoshida T, Ulrich A 2002. Palliative Care: the World Health Organization's global perspective. J Pain
Symptom Manage. 2002 Aug;24(2):91-6
2
Sternsward Jan, et al. The public health strategy for palliative care. J Pain Symptom Manage.2007;33(5):486–93. doi:
10.1016/j.jpainsymman.2007.02.016
3European Association for Palliative Care (EAPC). Recommendations of the EAPC for the Development of undergraduate
curricula in palliative medicine at European medical schools. EAPC 2013
4 APCA (2012) Core Competencies: A framework of core competencies for palliative care providers in Africa. APCA, Uganda
5
Palliative Care Australia. (2005) Standards for Providing Quality care for all Australians. Deakin West Australia, PCA
6 Worldwide Palliative Care Alliance. 2014. Global Atlas Report of Palliative Care at the End of Life
7
"The Palliative Care Trainers Declaration of Cape Town November 13, 2002". Journal of Palliative Medicine 6 (: 3): 339–340.
July 7, 2004
8WHA (2014) Strengthening of palliative care as a component of integrated treatment within the continuum of care. 134th
Session of the World Health Assembly. EB134.R7 May 2014
9
Frenk J, Chen L, Bhutta ZA et al. Health professionals for a new century: transforming education to strengthen health systems
in an interdependent world. Lancet 2010; 376: 1923–1958
10 Drake C. The importance of a values-based learning environment. The Journal of Moral Education Trust. 2007
11
WHO (2002), ‘Palliative care’. Available at www.who.int/hiv/topics/palliative/PalliativeCare/en/
12 Browing DM, and Solomon MZ (2006). Relational learning in pediatric palliative care: transformative education and the
culture of medicine. Child and Adolescent Psychiatric Clinics of North America, 15, 795-815
13 Kern DE, Thomas PA, Howard DM. Curriculum Development for Medical Education: A Six-Step Approach. Johns Hopkins
14 Downing J, Ling J, Benini F, Payne S, Papadatou D. (2014) A summary of the EAPC White Paper on core competencies for
education in paediatric palliative care. European Journal of Palliative Care 21(5) 245-249
15 Palliative Care Australia. (2005) Standards for Providing Quality care for all Australians. Deakin West Australia, PCA
16
APM. 2014 Curriculum for undergraduate medical education. APM, UK
17 APCA (2011) APCA Standards for Providing Quality Palliative Care Across Africa, APCA, Uganda
18 Meekin SA, Klein JE, Fleischman AR, Fins JJ. Development of a palliative education assessment tool for medical student
19
APCA. Kampala: APCA; 2012. Palliative care core curriculum. An introductory course on palliative
care. www.africanpalliativecare.org
20 Miller GE. The assessment of clinical skills/ competence/ performance. Acad Med (1990);65:s63-s67
46