American Journal of Hospice and Palliative

Medicine®
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A syllabus for fellowship education in palliative medicine

Susan B. LeGrand, Declan Walsh, Kristine A. Nelson and Mellar P. Davis
Am J Hosp Palliat Care 2003; 20; 279
DOI: 10.1177/104990910302000410

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A syllabus for fellowship education
in palliative medicine
Susan B. LeGrand, MD, FACP
Declan Walsh, MSc, FACP, FRCP (Edin.)
Kristine A. Nelson, MD
Mellar P. Davis, MD, FCCP
Abstract
Recent years have seen significant
growth in palliative medicine training
programs and positions.1 There are
plans to pursue palliative medicine spe-
cialty status with the American Board of
Medical Specialties and accreditation of
fellowship programs with the American
College of Graduate Medical Education.
A work group of program directors, sup-
ported initially by the Cleveland Clinic
and then by the American Board of
Susan B. LeGrand, MD, FACP, Director,
Palliative Medicine Fellowship Program, The
Harry R. Horvitz Center for Palliative Medicine,
The Cleveland Clinic Taussig Cancer Center,
Cleveland, Ohio.
Declan Walsh, MSc, FACP, FRCP (Edin.), The
Harry R. Horvitz Chair in Palliative Medicine, The
Harry R. Horvitz Center for Palliative Medicine,
The Cleveland Clinic Taussig Cancer Center,
Cleveland, Ohio.
Kristine A. Nelson, MD, Scientific Director, Cancer
Treatment Research Foundation, Arlington Heights,
Illinois; formerly, The Harry R. Horvitz Center for
Palliative Medicine, The Cleveland Clinic Taussig
Cancer Center, Cleveland, Ohio.
Mellar P. Davis, MD, FCCP, The Harry R. Horvitz
Center for Palliative Medicine, The Cleveland
Clinic Taussig Cancer Center, Cleveland, Ohio.
American Journal of Hospice & Palliative Care
Volume 20, Number 4, July/August 2003
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Hospice and Palliative Medicine, has medicine has been to have those current-
recently published standards for fellow- ly active in the field collectively agree on
ship training.2 Despite this, fundamental what the standards should be. Once in
questions remain about defining the field place, evaluation and analysis of the
and delineating the knowledge and skills standards can follow. The development
expected following completion of spe- of this curriculum proceeded in a similar
cialty training. In this article, we describe fashion. The clinical tasks of a palliative
the first fellowship program in palliative medicine specialist can be grouped into
medicine (PMP) in the United States, six key functions: communication, deci-
developed and supported by the Cleveland sion-making, symptom control, manage-
Clinic Foundation.3 The program has ment of complications, psychosocial
been implemented as part of the Harry care, and care of the dying.4 Therefore,
R. Horvitz Center for Palliative Medicine, we needed curriculum elements that
founded in 1987 as the first comprehen- addressed each of these functions. Our
sive integrated US program in this field. mission to train physicians skilled in
This training program, in existence since patient care, research, and advocacy also
1989, features a traditional rotational guided the curriculum.
structure with an inpatient primary care Given these functions and goals,
service, inpatient consult services, and an we defined the population of patients
outpatient consult/hospice service. This served. In our initial database of 1,000
article outlines the syllabus developed for patients and traditionally in hospice,
this fellowship, given what we believe to the overwhelming majority of patients
be the essential knowledge base for the had malignant disease.5 Therefore, an
field of palliative medicine. emphasis on the natural history, treat-
Key words: palliative medicine, ment, and complications of malignan-
education, hospice, training cy was imperative. Since the ultimate
goal is the availability of palliative
Curriculum development care for other complex illnesses, man-
agement of congestive heart failure,
How are standards devised for a chronic obstructive lung disease,
new field? The answer within palliative motor neuron diseases, and dementia
279
were added. A comprehensive list of
symptoms and complications was
obtained through brainstorming ses-
sions, review of the existing curricu-
lum from the European Association of
Palliative Care,6 and existing texts.
The initial list of subjects was devel-
oped and distributed to all staff and fel-
lows active in the program in 1998 for
review and suggestions. The current
schedule of lectures and orientation has
been derived from curriculum develop-
ment since academic year 1999. It
remains a work in progress with the
recent addition of administrative and
program development topics at the
request of fellows. Evaluation remains
informal since the number of individu-
als completing the program since initi-
ation of the curriculum is small.
Palliative medicine
We define six key functions for a
specialist in palliative medicine. These
areas overlap, with complex dynamic
interactions occurring in everyday med-
ical practice. Excellence in just one
area will enhance clinical care in the
others. Implicit in these functions is
the need for an interdisciplinary team
working with the physician. In order
to facilitate rapid integration into the
services, topics are introduced briefly
during an orientation period (See
Section I, Appendix). Education is
ongoing, supplemented by experience
with patients and journal reading.
While it is difficult to estimate
accurately the amount of time spent
on any particular area, we believe that
education in psychosocial, ethical,
communication, and spiritual issues
must not be overlooked. Excluding
educational experiences at the bed-
side, on rounds, and in interdiscipli-
nary team (IDT) meetings, the pro-
gram in palliative medicine (PMP)
dedicates 2.5 hours weekly to formal
structured teaching. By the comple-
tion of one academic year, approxi-
mately 30 percent of the time, or 40
280
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hours, is spent on teaching subjects with patients but also with families,
related to symptom control, manage- colleagues, and within the interdisci-
ment of complications, and the specif- plinary team. The syllabus elements
ic symptom issues of the dying for this function are outlined in
patient. We believe that a palliative Appendix Section II. Teaching modal-
medicine specialist should be pre- ities include mentoring, role-play, and
pared to provide primary management direct observation with immediate
of patients rather than functioning feedback and videotaping. Video-
only as a consultant, so at least another taping of patient/family encounters
30 percent of the curriculum (about 40 has proven more difficult than antici-
hours) is spent on specific diseases pated for a variety of reasons includ-
and appropriate therapies. The re- ing fellow reluctance, the need to
maining 40 percent, (52 hours) is obtain consent, and the delay required
spent on communication, psychoso- in setting up the equipment. The
cial issues, and cultural concerns. didactic teaching process begins with
While there are dedicated lectures on the presentation of communication
decision making, the majority of this protocols,11,12 suggested “scripted”
teaching is case-based and completed comments for certain situations, and
at the bedside or in the clinical setting. techniques for responding to patient/
We are committed philosophically family reactions. Following this, role-
and practically to a broad definition of play exercises and direct observation
palliative medicine and, in particular, (or video viewing) of patient and fam-
reject the term “end-of-life care.” The ily encounters are introduced. Fellows
symptoms and complications of ad- are instructed in conducting family
vanced disease may be present from meetings.13 There is a structured agen-
diagnosis,7,8 may worsen with treat- da, with a physician discussing the
ment and disease progression, and medical situation, establishing goals
ultimately require terminal care. The of care, and answering any medical
involvement of a palliative medicine questions. The social worker and
specialist is appropriate at any of these nurse then help patients and families
stages of disease, not just when a per- to process this information and make
son is actively dying. Defining the tentative discharge plans.
field as end-of-life care may have an Decision-making. The next impor-
adverse effect on appropriate and tant element is good decision-
timely referrals, and by default, nar- making. 12 This presumes effective
row the focus of the field. Our syl- communication, combined with a
labus is therefore designed and taught detailed patient history, physical
from this broader perspective. examination, and review of available
records. While good decision-making
A syllabus in palliative medicine is essential in care of the dying, once
the approaching death is actually
Clinical skills acknowledged, all other decisions
flow from that. If palliative medicine
Communication. A basic skill for has been involved in earlier stages of
achieving excellence in palliative the disease, additional more complex
medicine is good communication. All steps must be decided upon. A spe-
other skills are dependent upon this cialist in palliative medicine must
ability. Physician/patient communica- therefore be familiar with both pallia-
tion is complex and sometimes inade- tive and potentially “curative” treat-
quate, 9,10 but there is evidence that ment options for the diseases com-
good skills can be taught. 10 Effective monly encountered, including cancer,
communication is needed not only heart disease, chronic lung disease,
American Journal of Hospice & Palliative Care
Volume 20, Number 4, July/August 2003
neurological disorders, AIDS, and
others. Knowledge of the relative
risks and benefits are crucial to appro-
priately advising individuals and fam-
ilies struggling with treatment options.
The fundamental syllabus elements
for this function are disease-specific
knowledge (Section III, Appendix)
and decision making (Section IV).
Good decision making requires
judgment that develops with experi-
ence. Fellows must synthesize com-
plex clinical information, determine a
plan of care, and then be able to
defend those decisions when ques-
tioned. This technique is the mainstay
of bedside teaching. Problem lists and
a structured dictation style are routine-
ly used to help organize complex situ-
ations both past and present, develop
treatment priorities, and track any
complications of treatment or new
problems that arise. Routine involve-
ment in the IDT meetings helps fellows
appreciate the input of other disciplines
in the decision-making process. Details
of the IDT meetings have been previ-
ously described.3 The disease-specific
teaching modalities include fellow-led
didactic teaching, case conferences, and
didactic presentations by staff. Educa-
tion methods for ethics begin with a
didactic review during orientation that
is reinforced with case conferences and
teaching rounds. Decision-making skills
are taught primarily via mentoring and
teaching rounds.
Management of complications. Ad-
vanced diseases have both predictable
and unpredictable complications
(Section V, Appendix). 14 Quality of
life can be improved if these are antic-
ipated and managed proactively when
possible. For instance, palliative man-
agement of breast cancer or myeloma
patients requires knowledge of the
increased risk of pathologic fracture;
the radiographic findings of impend-
ing fracture; the role of bisphospho-
nates; and the role of interventions
such as radiation therapy or prophy-
lactic orthopedic procedures. In
American Journal of Hospice & Palliative Care
Volume 20, Number 4, July/August 2003
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another example, palliative medicine Psychosocial issues. The role of the
specialists must be knowledgeable physician in the management of psy-
about state-of-the-art management of chosocial issues may be the least
hypercalcemia but also be comfort- defined one. The involvement of an
able with the discussion about not interdisciplinary team in this area is
intervening. Therefore, our syllabus particularly important. Recent studies
addresses the common medical com- demonstrate a difference between
plications of advanced disease. Guide- patients and physicians in the impor-
lines and protocols for management tance they attach to spiritual issues
are under development. Teaching and psychosocial matters. Patients give
modalities include didactic (staff and these factors much higher priority. 20
fellow), x-ray rounds, and case-based The syllabus includes psychosocial
learning. concerns, cultural/religious diversity,
Symptom control. A palliative med- religious beliefs, discharge planning,
icine specialist must be well versed in homecare and hospice, and bereave-
pathophysiology of symptoms,12-17 ment (Section VIII, Appendix).19 Co-
differential diagnosis of symptoms in ordination of bereavement services in
advanced illness, pharmacologic man- the palliative medicine program is
agement,18,19 and appropriate use of handled predominantly by pastoral
testing, invasive procedures, and con- care and social work services within
sultants in advanced disease (also rel- our hospice. Each fellow needs a
evant in the management of com- working knowledge of grief issues,
plications). The syllabus, therefore, not only for speaking with families
includes pertinent pharmacology but also for their own emotional
(Section VI, Appendix) and the thera- health and support. Teaching in these
peutics of symptom management areas occurs during the two weekly
(Section VII). Fellows should be able IDT meetings (with hospice patients
to use, titrate, and rotate all available and other inpatients), didactic presen-
opioids and understand altered phar- tations, mentoring, and one-on-one
macology in renal or hepatic impair- discussions.
ment and in the elderly. 19 They must Care of the dying. The first step in
be sensitive to patient barriers to opi- effective care of the dying is to specif-
oid use, able to elicit these concerns ically identify the individual as being
effectively, and educate patients in days from death. The SUPPORT study
appropriate use. suggested that physicians are not
A specialist must also know the skilled at this task.7 Once this has been
uses, risks, benefits, and cost issues of determined, the focus of care should
most adjuvant medications. Although be on preventing and managing the
crucial, learning only about pharma- symptoms of the last 48 hours and the
cologic symptom management is not care of the bereaved family (Section
sufficient. A specialist also must know IX, Appendix).22 Teaching these skills
when other modalities, such as non- is predominantly case-based with an
pharmacologic treatments, radiation introductory didactic presentation.
therapy, chemotherapy, and interven-
tional pain management techniques Nonclinical skills
are appropriate. The use of a problem
list helps to track symptoms and their More is required of a specialist in pal-
response to various interventions. All liative medicine than just the clinical
teaching modalities (didactic, case- skills that lead to excellent patient care.
based, bedside teaching, and fellow- Fellows need to contribute to the re-
directed conferences) are used in search needed in this field, become edu-
symptom control education. cators and advocates, and demonstrate
281
knowledge of business concerns for
program and hospice development. To
this end, the syllabus includes non-
clinical skill areas.
Research. To be recognized as a
specialty as well as to improve patient
care, palliative medicine must have a
sound scientific base with a defined
research initiative. Consequently, fel-
lows are taught the ethics, processes,
practicalities, and priorities of pallia-
tive medicine research. These princi-
ples are presented in didactic sessions
at the weekly research meeting during
the first month of training. Fellows
also must complete the computer-
based Responsible Conduct of Re-
search course mandated by the
Cleveland Clinic Foundation. Their
training culminates in the completion
of a small research project reported in
a poster and/or manuscript for submis-
sion to a peer-reviewed journal. This
educational effort is particularly
important since most of their residen-
cy training will not have addressed the
practical, humanitarian, and ethical
difficulties encountered in research on
this very debilitated population with
complex medical problems (Section
X, Appendix).
Presentation skills. The need to edu-
cate others—consumers, physicians,
other healthcare professionals, and poli-
cymakers—is clear. Skilled speakers
who are passionate about their subject
can help to motivate others. Practice in
different styles of presentation and the
effective use of audiovisual aids are
included in the syllabus (Section XI,
Appendix), with current research on
adult learning also incorporated into the
planning. Each fellow prepares frequent
brief but formal presentations using
computer-generated slides or overheads.
Immediate feedback is given (usually
one-on-one) on the presentation style
and the slides themselves.
Business education. While our pri-
mary concern is not financial, fellows
need to prepare for involvement in pal-
liative medicine or hospice program
282
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development and/or management disease within their respective
issues that require economic viability. fields, only palliative medicine
We envision our fellows contributing manages all diagnoses.
to the national debate on improving
access to affordable palliative medi- • All ages. The geriatric specialist
cine. To do this they must have a basic handles similar problems but the
understanding of the current third-party specialty is age-defined. Pallia-
payer system; an understanding of the tive medicine specialists treat all
economics of hospitals, offices, and ages (pediatric palliative medi-
hospice23,24; and insight into how cine will likely develop inde-
physician decisions influence and are pendently).
influenced by these systems (Section
XII, Appendix). The syllabus includes • Symptom control. Anesthesia
specific lectures on each area and con- pain management programs have
tinuing emphasis on the impact of improved pain control for numer-
therapeutic decision making on hos- ous patients but are focused
pice costs.25 more on invasive interventions
and chronic nonmalignant pain.
Discussion Only palliative medicine focus-
es on the multiple symptoms of
As we train more physicians in the advanced disease.
field of palliative medicine, we must
prepare them for the jobs of the future, • Research. A new specialty must
which may include academic appoint- be “based on major new con-
ments, staff positions on inpatient pal- cepts in medical science.”25 We
liative medicine units or in consult have just begun to develop
programs, and serving as hospice unique tools to conduct research
medical directors or hospice physi- on this patient population. Pal-
cians. One might argue that a potential liative medicine patients are often
hospice physician should spend more excluded from research in other
time caring for the actively dying in fields given their complexity, the
homes and nursing facilities than severity of illness, the presence of
managing acute complications related end-stage organ failure and
to active treatment. We suggest that numerous comorbidities. Only a
the role of the palliative medicine spe- new specialty that is devoted to
cialist is a complex one. The specialist research in this complex popula-
needs to be a consultant to hospice tion will achieve this goal.
physicians in difficult cases, whether
they be the primary care physicians • Interdisciplinary teams. The in-
for patients with advanced disease or terdisciplinary team is the inte-
other subspecialists, e.g., the oncolo- gral structure for care delivery.
gist, cardiologist, or neurologist. While team interactions are im-
Therefore, we believe that trainees portant in many specialties,
need an intense learning experience as excellent palliative medicine can
outlined in this syllabus. Palliative only be practiced in the context of
medicine is unique in that it focuses a functioning team. No one indi-
on all of the following components. vidual can adequately assess all
the needs, address all the different
• Advanced disease. While the domains of care, and facilitate the
subspecialties of oncology, car- use of community resources for
diology, pulmonary medicine these medically frail, complex
and others deal with advanced patients and their families.
American Journal of Hospice & Palliative Care
Volume 20, Number 4, July/August 2003
 • Approach to the patient and
family as a unit of care. The
SUPPORT study showed the
troubling effects of serious med-
ical illness on caregivers. 7 The
recognition of the importance of
family in patient management
ultimately may decrease conflict
and facilitate subsequent be-
reavement.
• Recognition of the importance
of psychosocial and spiritual
domains. Medicine has become
increasingly focused on technol-
ogy and the disease process
rather than the treatment of the
person. One of the elements that
have set palliative medicine
apart is the need to attend to the
goals, values, and social, cultur-
al and spiritual background of
the individual and family. Only
when these factors are fully inte-
grated can a person with a com-
plex, life-threatening illness be
adequately managed.
As a field, palliative medicine has
been unique in its ability to attract
physicians from various backgrounds.
This factor complicates the develop-
ment of standards for admission to
training. The palliative medicine spe-
cialist must be a well-educated gener-
alist with a specialized focus. Does
prior training in anesthesia, psychia-
try, or other specialties adequately
prepare a physician to manage com-
plex internal medicine problems?
There is no easy answer to this ques-
tion. Additional educational modules
in managing specific problems may be
required, based on prior training.
The syllabus used by the Palliative
Medicine Fellowship program at the
Cleveland Clinic reflects our efforts to
define the field of palliative medicine
in the broadest terms. In developing it,
we reviewed the existing curriculum
from the United Kingdom and the
European Association of Palliative
American Journal of Hospice & Palliative Care
Volume 20, Number 4, July/August 2003
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Care. 26 Our curriculum differs in its in six clinical areas: communication,
greater emphasis on the therapeutic decision-making, management of
management of the diseases encoun- complications, symptom control, psy-
tered. We also reviewed the Core chosocial concerns, and care of the
Curriculum published by the Ameri- dying. We present a syllabus that
can Academy of Hospice and Pal- addresses all of these skills within a
liative Medicine. It is our opinion that well-established training program. We
this best outlines the skill set neces- encourage implementation of a simi-
sary for the nonspecialist physician lar structure in other programs, which
but is not comprehensive enough for will define the field in the broadest
fellowship training. The curriculum terms. Ultimately, we look for recog-
elements outlined by the recently nition of palliative medicine as a
established AAHPM standards are unique specialty to improve the care
fully addressed within this syllabus of the many patients living with
with two exceptions. The first is pedi- advanced incurable disease.
atrics. Our fellows, as in most estab-
lished programs, have little access to References
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 Appendix: Palliative Medicine Syllabus
B. Professional communication
I. Orientation9,10,15,16,20,26-29
1. Consulting
A. The philosophy of palliative medicine
2. Case presentations
1. History of palliative medicine/hospice
3. Structured problem lists
2. History of CCF program
4. Structured dictation
3. Structure of CCF program/policies/procedures
C. Interdisciplinary team agenda
B. Ethics
1. Focused case presentation
C. Principles of symptom control
2. Plan of care
D. Symptom assessment and recording
3. Discharge plan
E. Review of opioid pharmacology
4. Anticipated day of discharge
1. Preferred medications
2. Pharmacokinetics in the elderly, III. Disease Specific Knowledge31-34
renal and hepatic failure A. Oncology
3. Alternative routes of administration 1. Natural history of the most common malignancies
4. Pharmacoeconomics 2 Principles and palliative role of chemotherapy
F. Important drugs in palliative medicine 3. Principles and palliative role of hormonal therapy
G. Communication skills 4. Principles and palliative role of radiation therapy
1. Communication with patients/families B. Neurologic disease
2. Communication with colleagues 1. Natural history of the degenerative disorders—
H. Decision making ALS, MS, others
1. Balancing risks and benefits 2. Natural history of dementia
2. Deciding what is reasonable C. Cardiopulmonary/renal disease
3. Determining prognosis 1. Knowledge of protocols for end-stage congestive
I. Care of the dying heart failure
J. Current research protocols 2. Knowledge of protocols for end-stage COPD
3. Knowledge of protocols for end-stage renal disease
II. Communication Skills9,10,30
D. AIDS
A. Patient and family communication
1. Knowledge of associated pain syndromes
1. Protocol for the “bad news” conversation
2. Knowledge of medical complications
2. Techniques for active listening, body language,
3. Knowledge of pharmacologic complications
facilitation
E. Palliative medicine in pediatrics
3. Development of personalized communication
“scripts”
IV. Decision Making10,28
4. Techniques for discussion of prognosis and
advance directives A. Balancing risk and benefit
5. Management of difficult questions, emotional B. Determining patient preferences
reactions C. Assessing capacity

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 D. Determining competence E. Neurologic
E. Medical/legal issues 1. Spinal cord compression
F. Deciding what is reasonable 2. Brain metastases
1. Consulting 3. Meningeal carcinomatosis
2. Ordering laboratory tests and x-rays 4. Paraneoplastic syndromes
3. Procedures F. Hematolgic
G. Determining prognosis 1. Cytopenias
H. Patient/family discord in decision making 2. Thrombosis
I. Professional discord in decision making G. Metabolic
V. Medical Complications of Advanced 1. Hypercalcemia
Disease12,14,35-40 2. Adrenal failure
A. Cardiopulmonary 3. Disorders of sodium
1. Superior vena cava syndrome 4. Disorders of glucose
2. Pleural/pericardial effusion 5. Tumor lysis syndrome
3. Bronchial obstruction H. Lymphedema
4. Treatment related cardiomyopathy I. Infections
5. Radiation/chemotherapy related pulmonary fibrosis VI. Pharmacology17,41-51
6. Hemoptysis A. Opioid pharmacology
7. Lymphangitic spread 1. Morphine
B. Gastrointestinal 2. Oxycodone
1. Visceral obstruction 3. Hydromorphone
a. Esophageal 4. Fentanyl
b. Gastric outlet-including delayed gastric emptying 5. Methadone
c. Small and large bowel 6. Pharmacokinetics in the elderly, renal and hepatic
d. Biliary failure
2. Malabsorption 7. Alternative routes of administration
3. Hepatic failure 8. Barriers to appropriate use of narcotics
4. Ascites B. Other important drugs in palliative medicine
5. Hemorrhage 1. Corticosteroids
C. Bone 2. Neuroleptics
1. Prevention and management 3. Benzodiazepines
of pathologic fracture 4. Prokinetic agents
2. Rehabilitation 5. NSAIDs
D. Urologic 6. Bronchodilators
1. Obstruction 7. Antidepressants
2. Hemorrhage a. Tricyclic compounds
3. Renal failure b. SSRI compounds
4. Genitourinary fistula c. Psychostimulants

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 8. Anticonvulsants c. Bladder spasm
9. Laxatives/stool softeners d. Retention
VII. Symptom Control15,16,52-60 17. Mouth care
A. Symptom assessment and recording a. Dry mouth
1. Assessment tools b. Taste changes
2. Effects of patient characteristics on measurement c. Mucositis
3. Assessment and management of compliance problems i. Infectious
B. Principles of pain and symptom control ii. Other
C. Pain 18. Neuropsychiatric
1. Pathophysiology a. Cognitive assessment
2. Specific pain syndromes b. Diagnosis and treatment of delirium
3. Opioids in pain control c. Diagnosis and treatment of depression
4. Use of adjuvant medication d. Diagnosis and treatment of anxiety
5. Knowledge and appropriate use of e. Diagnosis and treatment of agitation
neurosurgical/anesthetic procedures f. Diagnosis and treatment of insomnia
6. Management of opioid side effects g. Appropriate use of consultants
7. Pain control in specific populations h. Assessment and management of suicidal ideation
a. Elderly
VIII. Psychosocial Care11,18,19,61-67
b. Pediatrics
c. Cognitively impaired A. Psychosocial Issues

d. Renal failure 1. Family dynamics in life threatening illness

e. Cultural differences 2. Family conferences

8. Nausea/vomiting 3. Role of complementary therapies—music, art etc.

9. Dyspnea, cough, hiccup B. Cultural/religious differences at end-of-life

10. Fatigue/weakness 1. Taking a spiritual history

11. Anorexia/cachexia 2. Knowledge of Christian traditions

12. Dyspeptic symptoms—early satiety/ a. Catholic

bloating/heartburn b. Protestant
13. Constipation/ bowel obstruction c. African-American
14. Diarrhea 3. Knowledge of Jewish traditions
15. Wound care/stoma care a. Orthodox
a. Prevention and treatment of decubitus ulcers b. Conservative
b. Management of fistulas c. Reform
c. Management of open wounds 4. Knowledge of Muslim traditions
d. Management of odor and drainage 5. Knowledge of Buddhist, Hindu
16. Genitourinary and other traditions

a. Dysuria 6. Spirituality

b. Incontinence 7. Mourning/burial rituals

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 C. Discharge planning D. Withdrawal of treatment
1. Cost issues 1. Discontinuing mechanical ventilation
2. Comparative cost of different medication. 2. Discontinuing dialysis
3. Cost issues relative to home care/hospice 3. Discontinuing artificial nutrition/hydration
4. Alternative methods of payment—indigent X. Research Education72-79
programs, samples
A. Research ethics
5. Efficient use of inpatient time B. Evidenced based medicine—understanding
6. Appropriate use of expensive modalities of treatment critical literature review
D. Homecare/hospice C. Clinical research methodology
1. Regulatory requirements for home care and hospice D. Symptom research methodology
2. Hospice benefits E. Protocol development
3. Impact of decision-making on hospice costs F. The scientific review committee and the
E. Bereavement institutional review board
1. Understand normal and pathologic grief responses XI. Presentation Skills80-84
a. Patient response to loss
A. Adult learning theory
b. Family response to loss/death
B. Effective use of audiovisuals
2. Predicting pathologic grief response
C. Didactic presentations
3. Managing pathologic grief response
D. Case-based presentations
4. Staff bereavement
E. Role-play
5. Appropriate management of personal grief reactions
6. Knowledge of appropriate support services XII. Business Education22,23,85-87

IX. Care of the Dying20,68-71 A. Understanding third-party payer system

A. Identification of the imminently dying B. Hospice Medicare benefit
B. Family preparation C. Inpatient metrics
C. Symptom management D. Hospice metrics
1. Terminal restlessness E. Home health metrics
2. Management of secretions F. Nursing home regulations
3. Sedation of the imminently dying

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