Hospice Curriculum / Didactic Guide - American Academy of …
Hospice Curriculum / Didactic GuideCurriculumDefinition of Palliative CareWHO definitionOther definitions including Center of Advanced Palliative Care, and National Consensus ProjectDefinition of hospice care General Principles of AssessmentCommon toolsEdmonton Symptom Assessment Scale (ESAS 0-10)Memorial Delirium Assessment Scale (MDAS 0-30)Functional scaleZubrod (0-5)Karnofsky performance scale (0-100)Prognostication Palliative Performance Scale (PPS)Functional Assessment Staging (FAST)Physical SymptomsPainDefinitionPain pathwaysPhysiology of pain – cancer and other terminal diseasesReceptors and neurotransmittersAssessment toolsVisual Analog Scale (VAS 0-100)Numeric Rating Scale (NRS 0-10)Brief Pain Inventory (BPI)FACESPain assessment in patients with dementiaTypes of painNociceptiveSomaticVisceralNeuropathicCentralPeripheralPain syndromesAnatomical EtiologicalPathologicalPharmacological management of pain – WHO ladder, NCCN guidelinesOpioidsTypesPharmacodynamics and pharmacokineticsSide effects including neurotoxicity and management of side effectsOpioid rotationDrug-drug interactionsOpioids in renal and hepatic diseaseOpioid regulationsRisk Evaluation and Mitigation Strategies (REMS) Adjuvant medicationsTypes – NSAIDs, steroids, anti-depressants, anti-epileptics, topicals, local anesthetics, bisphosphonates, NMDA receptor antagonists Pharmacodynamics and pharmacokineticsSide effectsDrug-drug interactionsAdjustment in renal and hepatic diseaseCost considerationsEvidenceNon-pharmacological managementAnesthetic proceduresPrinciplesIndicationsEvidenceTypes of blocks – common blocks including trigger point injections, celiac plexus, stellate ganglion, intercostal, neurolytic blocks, radiofrequency lesions, vertebroplasty, kyphoplastyPrinciples of spinal delivery of analgesicsAppropriate referral to pain serviceCost considerationsNeurosurgical proceduresPrinciplesIndicationsEvidenceTypes of procedures – common procedures including dorsal root entry zone lesions (DREZ), myelotomy, cordotomyCost considerationsCognitive behavioral therapy (CBT)AcupunctureTranscutaneous electrical nerve stimulation (TENS)Physical and occupational therapy techniquesNausea/vomitingAnatomy of pathways and nausea/vomiting centers, including chemoreceptor trigger zone (CTZ) and their interrelationshipPathophysiology of nausea/vomitingCausesAssessmentManagementPharmacologicalDopamine antagonists – haloperidolProkinetic agents – metoclopromide, domperidonePhenothiazines – prochlorperazine, chlorpromazine, olanzapineAnti-histamines – cyclizine, diphenhydramine, promethazineAnti-cholinergics – hyoscine5-HT3 antagonists – ondansetron, granisetronSubstance P/NK 1antagonist – aprepitant Non-pharmacological – cognitive behavioral therapy, TENS, acupuncture/acupressureConstipation/diarrheaConstipationDefinition – ROME criteriaPathophysiologyCauses – opioid-induced constipation (OIC)Assessment – history, physical exam including rectal, imagingManagementProphylactic treatmentPharmacological treatment – stool softeners, stimulants, enemas, opioid antagonists, natural productsNon-pharmacological treatment – hydration, exerciseDiarrheaDefinitionCausesAssessment – history, physical exam, imaging/investigationsManagementSymptomaticAbsorbent agents – bulk-formingAdsorbent agents – kaolin, chalkProstaglandin inhibitorsOpioid agentsAnti-cholinergicsSomatostain analogues - octreotideSpecificDyspneaAnatomyPhysiology of Respiration and neural mechanismsReceptorsChemical control mechanisms – peripheral chemical receptors, central chemical receptorsDefinition of dyspneaIncidenceCausesAssessment of dyspnea – verbal numeric scale, modified Borg questionnaireOxygen cost diagramLung function testsTreatmentGeneral principlesTreatment of reversible causesSymptomatic treatmentPharmacological – bronchodilators, corticosteroids, opioids, oxygenNon-pharmacological – relaxation techniques, fan ventilation of the room DeliriumCausesAssessment – Memorial Delirium Assessment Scale (MDAS), mini-mental state exam (MMSE), CAM TreatmentTreat reversible causes (eg, antibiotics)Opioid rotationSimplifying polypharmacyTreat metabolic abnormalities (eg, hypercalcemia)Symptomatic treatmentPharmacological – anti-psychotics (eg, haloperidol, olanzapine, quetiapine, chlorpromazine), benzodiazepinesNon-pharmacological – quiet room, caregiver presence, safety measures, counseling family membersAnorexia/cachexiaDefinitionCauses – metabolic, inflammatoryAssessment – cachexia panel (including anthropometric measures), markers (c-reactive protein, ESR) FatigueDefinitionDifferential diagnoses – fibromyalgia, chronic fatigue syndrome, post-traumatic stress disorderPathophysiologyCausesTreatmentSpecific – underlying cause (eg, anemia)General measuresPharmacotherapy – amphetamines, steroids, anti-cholinergicsNon-pharmacological – exercise, light therapyWounds TypesFungating woundsPressure ulcersAssessment and diagnosisCausesTreatmentGeneral measures – prevention, wound irrigation, debridement, dressing, treatment of infectionPharmacological – antibiotics, dressings (alginate hydrofiber or foam dressings for high-volume exudate wounds)Non-pharmacological – hyperbaric oxygen therapy, vacuum-assisted wound closure therapyPruritusCauses – localized and generalizedPathophysiology Neural pathwaysAssessmentCausesManagementGeneral measures – hydration, exposure to UV light, cognitive behavioral treatment (CBT), acupuncture, topical agents (corticosteroids cream, lidocaine jelly, capsaicin cream, doxepin cream)Pharmacological / Systemic Agents – H2-receptor antagonists, 5HT3-receptor antagonists, opioid-receptor antagonists, NSAID’s, SSRI’s, cholestyramine, thalidomide, UVB, psoralen + UVA (PUVA)Step ladder approach for disease-specific (eg, uremia, cholestatic, paraneoplastic pruritis)HiccupsPathophysiologyCausesTreatmentGeneral / traditional measures – stimulation of soft palate, sucking on a spoon of sugarPharmacological – metaclopromide, haloperidol, chlorpromazine, baclofen, gabapentinMucositisDefinitionRisk factorsCausesStagesPreventionGeneral measures – oral hygiene, hydration, benzydamine swish and spitSpecific measures – including preventive medications and measures (magic mouthwash)Symptom management including painTreatment of infections – bacterial , viral, fungal CoughPathophysiologyCauses AssessmentGeneral measures – treat the cause, physiotherapy, positioning of patientPharmacotherapy – decongestants, anti-histamines, bronchodilators, proton pump inhibitors, antibiotics, nebulized saline, nebulized local anesthetics, corticosteroids, anti-cholinergics, cough suppressants (opioids, detromethorphan, benzonatate, sodium cromoglycate), expectorants (mucoactive agents, e.g. guifenesin), mucolytics (N-acteylcysteine)Neurological disordersCausesStrokeMultiple sclerosisAmyotrophic lateral sclerosisParkinson’s diseaseHuntington’s diseaseDementiaTypesPathophysiologyTreatmentGeneral measuresPharmacologicalAdvanced planning – feeding, control of secretions and spasticityHospice indications, benefitsCOPDDefinitionPathophysiologyTreatmentGeneral measuresPharmacological – bronchodilators, oxygen, inhaled steroids, antibioticsAdvanced planning – counseling, DNRCHFDefinitionClassificationDisease course and epidemiologyPathophysiologyTreatment – ACE inhibitors, beta-blockers, vasodilators, diureticsManagement of defibrillatorsAdvanced planning – DNR Neuropsychiatric SymptomsAnxietyAssessmentCausesTreatmentPharmacological – benzodiazepines, anti-depressants, neuroleptics, beta-blockersNon-pharmacological – expressive supportive counseling, relaxation techniques, meditationDepressionAssessment – DSM IV criteria, two-point questionnaire, HADSCausesRisk factorsTreatmentPharmacological – TCA’s, SSRI’s, SNRI’s, anti-psychotics, psychostimulants Non-pharmacological – expressive supportive counseling, cognitive behavioral therapy (CBT), guided imagery, relaxation training, individual and group therapy, structured counselingAdjustment disorderAssessmentCausesDisease courseTreatmentSleeping disordersAssessment – DSM IV criteriaTypes – primary sleep disorders (dissomnias, parasomnias), secondary sleep disorders (due to general medical conditions, substance-induced)CausesAssessment – history, EEGTreatmentNon-pharmacological – sleep hygiene measures, behavioral interventions (stimulus control, imagery training, progressive muscle relaxation, sleep deprivation methods, light therapy)Pharmacological – hypnotics, anti-depressants, neurolepticsPersonality disorders – Axis IICoping skillsHope in end-of-life carePalliative Care EmergenciesSpinal cord compressionSymptomsDiagnosisTreatmentPharmacotherapy – steroids, opioidsRadiation/SurgeryHypercalcemiaCausesClinical presentationTreatment – fluids, steroids, bisphosphonates, calcitonin, other agentsHemorrhageCausesTreatmentPharmacotherapy – benzodiazepines, anti-fibrinolytics, thrombin, hemostatic agents (epinephrine) Non-pharmacotherapy – bleeding pack, pressure, stents, posture, Surgery/radiationSeizuresCauses – cancer-related, non-cancer causesTreatmentPharmacologicalGeneral measuresSpecific drugs – benzodiazepines, anti-epileptics drugs, steroidsSurgery/radiation (gamma-knife)PrognosticationGoal settingSuicideRisk factorsAssessment – active with plan, ideation without planStrategies of managementRequest for assisted suicideDesire for hastened deathEuthanasia – Death with Dignity Act of OregonThe Dying Patient and FamilySigns and symptoms of impending deathAssessmentFamily counselingBereavement issues with familyFuneral arrangementsProcedures in Palliative Care – Paracentesis, Thoracentesis, Interventional Pain TechniquesPharmacology and TherapeuticsPharmacodynamics of commonly used drugs in palliative care including pediatricsPharmacokinetics of opioids and non-opioidsMetabolites and implications of opioids and non-opioidsOrgan failure and medications with reference to opioidsCommon drug-drug interactionsPsychological Care and InterventionsAnxiety, depression, adjustment reaction, sleeping disorders, TreatmentPharmacotherapyBenzodiazepinesAnti-depressantsAnti-psychoticsNon-PharmacotherapyCounselingPsychotherapyGroup TherapyNatural agentsSocial and Family RelationshipsFamily careDefining the familyThe family’s needsFamily pain managementInformation needsPhysical care needsFamily communication and family functioning issuesSocial and financial pressuresChildren of palliative care patientsCommunication TechniquesComponents of good physician-patient communicationInformation needs of palliative care patientsCurrent practice in information provision in palliative care and oncologyInterventions to help meet patients’ information needs and promote involvement in the consultationGrief and BereavementGrief Anticipatory griefPhases and duration of griefNormal vs. pathological griefBereavementEmotional supportInterventions – support services, preventative intervention program, psychotherapeutic interventions, pharmacological therapiesCultural and Ethnicity AspectsSocioeconomic factors, level of educationCultural sensitivity regarding customs, decision makingSpirituality and ReligiosityReligion and medicineSpiritual needsReligious psychologyHospital chaplainsReligious studiesCultural aspects and specific ritualsMedical Ethics – Withholding and Withdrawing TreatmentLegal Implications in Palliative Care – DNR, Assisted Suicide, EuthanasiaProcedure After Death – death certificate, autopsy, medical examiner, cremation regulation, rituals, postmortem organ donationPhysician-Patient RelationshipShare decision makingLeadership Skills and TeamworkTeam dynamicsLeadership stylesConflict resolutionAdult Learning Techniques and Various Teaching MethodsOne minute preceptorSmall group didactics Personal learning style and reflective practiceRoles of mentor and menteeBasic Research TechniquesChallenges of research in palliative careDefining the patient populationStudy designsOutcomes measurementEthics in palliative care researchPediatric Palliative CareDiseases in pediatric palliative careSymptom assessmentCommunicating at level of development of the childBereaved family and needs of siblingsHospicePhilosophyMedicare Hospice benefit, reimbursement, cost containmentAdministrative structureStaffingEligibility criteria for hospice admissionInterdisciplinary team interactions including bereavement counselor and volunteersCommunity Healthcare SettingsAdmission criteria and logistics of community-based nursing home, skilled nursing facility, and long-term acute care facilities for chronic debilitating illnessContinuity across clinical settingsAccess to palliative care in the communityQuality Improvement in Palliative CareAuditingNational guidelines and care standardsClinical quality improvement and audit initiativesDidacticsCore Curriculum Conference Schedule?The curriculum is comprehensive, and designed to reach all milestones of palliative medicine specialist training. Building on the core of patient care, training includes didactic core lectures, case conferences, journal club, opportunity for research, and close faculty tutoring.?Didactic Sessions?A weekly fellows’ conference is held for palliative care and its trainees that includes book chapter review, board-review questions, and fellows’ presentations on cases, quality improvement and research topics.Frequency – Every week 1-1.5 hrsTopics of Discussion, Complex Case Reviews, Intra/Interdisciplinary Conferences, board reviewsPalliative care assessment tools and scales Pharmacology of analgesics—opioidsPharmacological and non-pharmacologic management of painOpioid RotationCase Studies for opioid conversionAdjuvant medicationsGI symptoms management in palliative carePalliative sedationInterventional pain medicine proceduresPrognosticationsHospiceAdministrative aspects of hospice and regulations to knowBilling LectureCardiology-heart failure prognosticationNeurology-stroke prognosticationEthicsPalliative care in critically ill patientsIntegrating palliative care and geriatric MedicinePediatric palliative careEthical and legal issues in Palliative CarePediatric pain managementCystic fibrosisNoninvasive ventilationDelirium-psychiatryDepression-psychiatryPrognostication in dialysis patientsEnd stage liver diseasePalliative interventions in GISpiritual care at bedsideCommunication/breaking bad newsCommunication with dying patients and their families and surrogatesCare Of imminently dyingEnd stage Dementia and Palliative CareCaregiver: The Hidden PatientBereavementGoals of care including understanding of developing a and dissemination of the plan to cliniciansPalliative Care ResearchJournal Club?Each fellow selects, reviews, and presents a journal club article at least every other month at the journal club, detailing the importance of the chosen paper, its impact on clinical practice, and the pros/cons of the study design.Frequency – every week 1-1.5 hrsSpiritual Care/Grief SessionsSeven-week summer seriesTime: 10:30 am-Noon every FridayPalliative Medicine CMEFull-day courseOnce-a-yearBoard Review SessionsFrequency – at least once a month 1-1.5 hrsReferences:Seasons Hospice and Palliative Care ( Des Plaines, IL)The University of Texas MD Anderson Cancer Center Hospice and Palliative Care ProgramGeisinger Health Hospice and Palliative Care ProgramAlbert Einstein College of Medicine Department of Family and Social Medicine, Palliative Care Services ................
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