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The RACGP Curriculum for Australian General Practice 2016

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Curriculum coverThe complete 2016 Curriculum consists of a number of units in addition to contextual units. All units will be available for download as a PDF shortly.

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Palliative care

Definition

Palliative care is the active total care of patients whose disease is not responsive to curative treatment. Control of pain and other symptoms, and psychological, social and spiritual issues, is paramount to provide the best quality of life for patients and their families.1 Palliative care is also by definition 'team care'2 and so careful assessment of symptoms and the needs of the patient should be undertaken by a multidisciplinary team.

The World Health Organization3 defines palliative care as:

'An approach that improves the quality of life of patients and their families facing the problem 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 or 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/carers cope during the patient's illness and in their own bereavement
  • uses a team approach to address the needs of patients and their families/carers, including bereavement counselling if indicated
  • enhances quality of life, and may also positively influence the course of illness, and
  • 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'.

Curriculum in practice

The following typical presentation illustrates how the palliative care curriculum applies to general practice:

  • Pete, 68 years of age, is a truck driver. He was forced into retirement due to lower back pain, which became severe enough to disturb his sleep. He managed his pain by increasing his alcohol intake, which led to marital problems culminating in separation. By the time he presented for review, he was living in a caravan and had several months of poor nutrition. Unfortunately his pain was found to be due to multiple myeloma, which proved resistant to treatment including bisphosphonates and a short course of radiotherapy. He has had a recent hospital admission for pneumonia and continues to smoke. His pain is currently well managed, however he does not take his other medications as recommended. This includes warfarin, which was commenced in hospital due to his limited mobility posing a risk of DVT. He rarely attends planned appointments, citing lack of transport, and you assess his psychosocial circumstance as placing him at high risk. As Pete's physical and emotional condition is likely to deteriorate as his disease advances, who can you involve in forward planning his future health needs?

Rationale and general practice context

Palliative care requires a multidisciplinary approach, with the general practitioner playing a central and increasing role, especially in the management of domiciliary care. For example, in 2002, of the approximate 134 000 deaths that occurred in Australia, about 64 000 (almost 50%) of patients would have been cared for by a GP several times during their last 12 months of life.4

Most patients who die an easily predictable death from a diagnosed terminal illness want to be cared for at home (>50%). However, only about 16% are able to exercise this option, as most patients now die in hospital; only 20% of people die in hospices and 10% in nursing homes.5

The community sector is increasingly caring for people at home rather than in hospital, and GPs often coordinate sometimes fragmented and competing community services and advocate on behalf of patients, their families and carers for community based palliative care.6 7

Like other doctors, GPs are largely trained to work with curative or life prolonging models of health and many GPs have identified that they require further education in the skills that underpin the practice of palliative care, such as basic communication skills, symptom control and management skills, and skills for dealing with 'death and dying'.8

The provision of good general practice and community based palliative care requires GPs to organise their practices appropriately to help build and configure best use of community based health networks (eg. specialist hospital based to community based teams) to meet the palliative care needs of their patients, and their families and carers, for quality, comprehensive healthcare at the end-of-life in the setting of their choice.9

Like any other area of medicine, GPs need to utilise evidence based clinical decisions when providing general practice palliative care and access current palliative evidence bases such as CareSearch10 and Therapeutic guidelines - palliative care.11

There are government initiatives in palliative care, and GPs need to work in conjunction with government health priorities and other organisations toward better palliative care services.

What are the core elements of general practice palliative care?

Core education requirements for the palliative care curriculum need to ensure12 13:

  • physical aspects of care - close and detailed attention to symptom recognition and management, and knowledge of the pharmacology of medications, including dosing in elderly or renally impaired patients
  • psychosocial aspects of care - emotional, social and spiritual aspects of end-of-life care, including developing specific communication skills needed to discuss end-of-life issues with patients and their families/carers
  • cultural issues - crosscultural issues, appropriate use of independent interpreters
  • ethical issues - state based legal requirements with death, wills and end-of-life issues, including managing requests for euthanasia and requests to hasten death with counselling and understanding
  • teamwork - how to work in a multidisciplinary team, how to coordinate different models of care for best patient and family/carer outcomes
  • practical issues - practice issues around 24 hour care rostering, and appropriate use of Medicare Benefits Schedule items to sustainably practise equitable palliative care for patients, determined on the basis of need
  • carer support - respite arrangements, depression screening and support, emotional support and bereavement care, and understanding and recognising risk factors that may predict the early onset of psychosocial distress and complicated grief reactions14 in family members and carers to enable appropriate referral for further psychosocial support
  • career-long learning - critical appraisal of the evidence base used for own practice and developing primary palliative care research skills to update own evidence base, as well as developing community education, advocacy and health promotional skills
  • complementary and alternative medicine15 16 - developing skills to help patients and their families/ carers to be able to assess their own use of complementary therapies from an evidence based and/or safe perspective
  • audit, care pathway and outcome measurement - developing skills to measure own practice in the area of palliative care (eg. developing an end stage care pathway audit tool17) and be able to audit clinician use of symptom assessment lists and outcome measures (eg. pain scales).

Related curriculum areas

Training Outcome of the five domains of general practice

1. Communication skills and the patient-doctor relationship

PALT1.1

Establish and foster effective and empowering relationships with patients and their families as partners in care decisions, as well as with other healthcare professionals.

PALT1.2

Use good communication skills including active listening, breaking bad news, dealing with difficult questions, discussing end-of-life issues and crosscultural care at the end-of-life.

PALT1.3

Understand the experience and consequences of disease from the perspective of the patient and their family.

PALT1.4

Help patients live as creatively and meaningfully as possible all the way to the end-of-life.

PALT1.5

Be sensitive to differing perceptions and expectations of disease and treatment among various family members.

PALT1.6

Be aware of spiritual, religious and cultural issues.

PALT1.7

Understand the normal process of grief, help prepare carers for bereavement and offer support during this process.

2. Applied professional knowledge and skills

PALT2.1

Use evidence based clinical decisions when providing general practice palliative care and access current palliative evidence bases (eg. CareSearch and Therapeutic guidelines - palliative care).

PALT2.2

Appreciate and understand the broad range of terminal illnesses (eg. malignancy), neurological degenerative disease (eg. motor neurone disease, end stage dementia), organ failure (eg. chronic obstructive pulmonary disease, congestive cardiac failure), frailty and dementia, and HIV/AIDS.

PALT2.3

Understand the potential treatments available, both disease specific and for symptom control, including palliative surgery, radiotherapy and chemotherapy.

PALT2.4

Anticipate, diagnose and manage potential problems, either disease related or iatrogenic.

PALT2.5

Understand indicators of disease progression.

PALT2.6

Demonstrate a good understanding of drugs commonly used in palliative car (indications, doses, side effects, routes of administration).

PALT2.7

Be familiar with the use of appropriate subcutaneous infusion devices in palliative care.

PALT2.8

Understand the implications of renal and hepatic impairment.

PALT2.9

Be familiar with dose equivalence of opioids and be able to recognise signs of opioid toxicity.

PALT2.10

Be aware of possible interactions between prescribed drugs and any complementary and alternative medicines patients may be taking, or be able to refer to available databases to advise patients on the available evidence of efficacy, safety and adverse interactions.

PALT2.11

Identify symptoms and therapeutic responses (including counselling and psychosocial support).

PALT2.12

Be able to diagnose and identify the causes and appropriately manage common symptoms of many end-of-life conditions including:

  • pain (nociceptive, visceral, neuropathic and complex)
  • nausea and vomiting
  • constipation
  • anorexia
  • hiccups
  • fatigue, weakness and lethargy
  • mouth care
  • delirium and confusion
  • dyspnoea
  • depression and anxiety
  • existential distress
  • pressure area care
  • malignant effusions
  • peripheral lymphoedema
  • terminal phase events (eg. agitation, distress, 'noisy breathing', restlessness, haemorrhage and seizure).
PALT2.13

Be competent in recognising and appropriately managing and/or referring on patients with potential emergencies at the end-of-life such as:

  • opioid toxicity (especially in renal failure)
  • neutropaenic sepsis
  • hypercalcaemia
  • bowel obstruction
  • seizure
  • spinal cord compression
  • haemorrhage.

3. Population health and the context of general practice

PALT3.1

Be aware of the services available within the community and the means of accessing these services.

PALT3.2

Coordinate these services in the care of the patient and also consider health beyond that of the individual patient. This involves an advocacy role regarding community needs, including promoting the needs of disadvantaged groups. Part of this may involve developing crosscultural partnerships.

PALT3.3

Be aware of the needs for bereavement support, and appropriate referral or management of complicated grief reactions.

PALT3.4

Help allocate finite healthcare resources prudently to best serve the health needs of the population on the basis of need and equity of access to care and support.

4. Professional and ethical role

PALT4.1

Display a professional attitude and be able to analyse and understand the ethical dimensions of clinical scenarios in palliative care.

PALT4.2

Negotiate and agree on treatment modalities, priorities and goals of treatment.

PALT4.3

Respect patient wishes to decline treatment.

PALT4.4

Understand the issues surrounding euthanasia, 'relief of suffering' at the end-of-life, and patient and community perspectives on a 'good death'.

PALT4.5

Understand the issues surrounding advance health directives and end-of-life planning, including the need to complete 'unfinished business'.

PALT4.6

Be prepared to advocate strongly for patient needs.

PALT4.7

Reflect on own personal beliefs and the impact of these on interactions with patients and their care.

PALT4.8

Have an ongoing commitment to professional development that promotes the best available evidence based practice. Use this knowledge to provide patients with the best management.

PALT4.9

Be aware of and respect how the spiritual, religious and cultural issues specific to each patient affects their perception of illness and death, and treatment decisions made in partnership with the patient and their family/carers.

PALT4.10

Recognise any personal emotional stress and seek assistance appropriately.

PALT4.11

Communicate effectively within multidisciplinary teams, including community organisations and administrative bodies, to promote quality care and optimise palliative care health outcomes.

PALT4.12

Advocate, where appropriate, on behalf of patients.

5. Organisational and legal dimensions

PALT5.1

Understand the complexities of, and commitment to, working as part of a multidisciplinary team.

PALT5.2

Be able to work with several models of healthcare and service delivery, and be able to coordinate and integrate these services collaboratively and seamlessly for the best care of the patient.

PALT5.3

Be aware of local medical, nursing, allied health, community and respite services.

PALT5.4

Be able to locally access appliances as aids to daily living for patients.

PALT5.5

Be familiar with state legal requirements for:

  • carer's allowances
  • advance health directives
  • enduring power of attorney/enduring power of guardianship
  • preparation of a will.
PALT5.6

Be familiar with identification and certification of death, and surrounding legal issues.

PALT5.7

Structure the clinic/practice to accommodate home visits for palliative patients, when appropriate, and arrange adequate clinical handover to partners or preferred after hours providers to ensure continuity of care at all hours for palliative care patients and their families.

PALT5.8

Be aware of nontime based Medicare Benefits Schedule (MBS) items that reward team care and planning.

Learning objectives across the GP professional life

Medical student

1. Communication skills and patient-doctor relationship

PALLM1.1

Describe specific communication skills to be able to best care for patients and their families/carers at the end-of-life, and the families/carers progress beyond the patient's death during their bereavement phase.

2. Applied professional knowledge and skills

PALLM2.1

Describe the pathology, including both malignant and nonmalignant terminal and chronic illness, and some understanding of prognosis and quality of life issues.

PALLM2.2

Describe the anatomical and physical aspects of incurable, life-limiting disease processes.

PALLM2.3

Outline how a significant proportion of patients with incurable diseases require the doctor to exhibit skills for 'caring' rather than 'curing' and how to help patients and their families/carers to prioritise care on the basis of quality of life.

3. Population health and the context of general practice

PALLM3.1

Describe the role of the GP in the palliative care setting and GPs operating within a multidisciplinary framework to provide palliative care to patients from a holistic, physical, psychosocial and spiritual perspective.

4. Professional and ethical role

PALLM4.1

Be able to seek help and care for one's own physical, emotional, social and spiritual needs in this emotionally challenging area of work.

5. Organisational and legal dimensions

PALLM5.1

Outline team care and care planning arrangements that are possible for both funding and organising care in the general practice palliative care setting.

Prevocational doctor

1. Communication skills and patient-doctor relationship

PALLP1.1

Demonstrate skills in taking a thorough history (physical, emotional, psychosocial and spiritual) in a patient with a life-limiting illness.

PALLP1.2

Demonstrate skills in competently communicating 'bad news' and discussing prognosis, and empathically being able to redefine realistic goals for 'hope' and 'care' at the end-of-life.

2. Applied professional knowledge and skills

PALLP2.1

Demonstrate skills in being able to elicit reporting of common symptoms seen in palliative care, be able to use symptom checklists and screening tools when needed, and organise a prioritised management checklist in line with the patient's and/or their family's wishes.

PALLP2.2

Demonstrate skills in being able to organise appropriate investigations in a palliative patient, taking into consideration the context of the patient's illness.

PALLP2.3

Demonstrate skills in being able to perform a thorough examination in a patient with a life-limiting illness.

PALLP2.4

Describe the drugs commonly used in palliative care and their indications, doses and routes of administration.

3. Population health and the context of general practice

PALLP3.1

Describe how to assess and describe each patient's links to family and friends.

PALLP3.2

Demonstrate an ability to advocate for equity of access to multidisciplinary palliative care services, particularly for those from disadvantaged groups and their families/carers.

4. Professional and ethical role

PALLP4.1

Demonstrate skills in being able to devise comprehensive management plans in partnership with patients and their families/carers to enhance quality of life at the end-of-life.

PALLP4.2

Describe self care measures in place for the treating GP and other care team members.

5. Organisational and legal dimensions

PALLP5.1

Demonstrate familiarity with completing death certificates, advanced health directives, enduring guardianship requirements, carer's allowance applications and other legislative and administrative requirements relevant to palliative care and end-of-life issues.

Vocational registrar

1. Communication skills and patient-doctor relationship

PALLV1.1

Demonstrate awareness in defining the realistic context of illness at the end-of-life for the patient and their family.

PALLV1.2

Demonstrate specific communication skills in dealing with end-of-life issues such as giving bad news, counselling regarding realistic expectations and hope, nutrition and hydration, and exploring and managing requests for euthanasia.

2. Applied professional knowledge and skills

PALLV2.1

Demonstrate skills in managing bereavement issues for families/carers and coordinating services to meet these needs when ongoing care and support is required.

PALLV2.2

Demonstrate management skills in dealing with the psychological, social, cultural and spiritual aspects of the patient's illness and the impact of these on patient care.

3. Population health and the context of general practice

PALLV3.1

Demonstrate establishment of relationships and networks with other community services that are necessary to provide quality palliative care (eg. nursing, allied health and domicillary services) equitably across the local population as needed.

4. Professional and ethical role

PALLV4.1

Demonstrate skills in dealing with ethical issues in patient care at the end-of-life.

5. Organisational and legal dimensions

PALLV5.1

Demonstrate the ability to lobby local health service providers to provide essential health services for palliative care patients, as needed, in the patient or carer's preferred place of care.

PALLV5.2

Demonstrate the ability to advocate on behalf of patients in relation to meeting their palliative care needs.

PALLV5.3

Demonstrate awareness of the palliative care services available in the patient's community, and be able to access these services to optimise patient care.

PALLV5.4

Demonstrate familiarity with completing death certificates, advanced health directives, enduring guardianship requirements, carer's allowance applications and other legislative and administrative requirements relevant to palliative care and end-of-life issues in the general practice setting.

Continuing professional development

1. Communication skills and patient-doctor relationship

PALLC1.1

Demonstrate a commitment to upskilling regularly in communication skills acquisition associated with managing challenging end-of-life issues for patients and their families/carers.

2. Applied professional knowledge and skills

PALLC2.1

Demonstrate evidence of updating own knowledge and skill base in the light of new and emerging evidence in palliative care.

3. Population health and the context of general practice

PALLC3.1

Describe the demographics of terminal illness, especially in relation to nonmalignant conditions.

PALLC3.2

Demonstrate a commitment to forging and maintaining relationships with other community palliative care service providers to provide equity of access on the basis of need.

PALLC3.3

Demonstrate access to current palliative evidence bases (eg. CareSearch and Therapeutic guidelines - palliative care).

PALLC3.4

Describe and implement, where appropriate, policies and standards for palliative care.

4. Professional and ethical role

PALLC4.1

Demonstrate planning on how to undertake ongoing professional development in relation to identified palliative care knowledge gaps.

5. Organisational and legal dimensions

PALLC5.1

Demonstrate the ability to identify gaps in own knowledge, skills and attitudes in relation to evidence based palliative care.

PALLC5.2

Outline practice financial aspects and time management issues related to effective palliative care general practice service provision.

PALLC5.3

Undertake regular audits of management practices in dealing with palliative care patients and their families/carers.

References

  1. Department of Health and Ageing. Palliative care. 2010. Available at www.health.gov.au/palliativecare.
  2. Mitchell GK. Whither general practice palliative care? Aust Fam Physician 2006;35:757.
  3. Word Health Organization. World Health Organization definition of palliative care. Geneva: World Health Organization. 2011. Available at www.who.int/cancer/palliative/definition/en.
  4. Palliative Care Australia. A guide to palliative care service development: a population based approach. Canberra: Palliative Care Australia; 2005.
  5. Care Search Palliative Care Network. Preferred place of death. 2008 Available at www.caresearch.com.au/caresearch/tabid/407/Default.aspx.
  6. Australian Health Ministers' Advisory Council. From hospital to home - improving care outcomes for older people. A national action plan 2004–2008.
  7. Australian Institute of Health and Welfare. Older Australia at a glance. 4th edn. Canberra: Australian Institute of Health and Welfare; 2007.
  8. Cairns W, Yates PM. Education and training in palliative care. Med J Aust 2003;17(Suppl):S26-8.
  9. Storey L Pemberton C Howard A, et al. Place of death: patient choice or Hobson's choice? Cancer Nursing Practice 2003;2:4-10.
  10. CareSearch. Palliative care knowledge network. 2011. Available at www.caresearch.com.au/Caresearch/Default.aspx.
  11. Therapeutic Guidelines. Palliative care. Version 3. Melbourne; 2010. Available at www.tg.org.au/?sectionid=47.
  12. The Royal College of General Practitioners. Care of people with cancer and palliative care. 2007. Available at www.rcgp-curriculum.org.uk/PDF/curr_12_Cancer_and_palliative_care.pdf.
  13. Australia and New Zealand Society of Palliative Medicine. Palliative care curriculum for undergraduates (PCC4U). 2010. Available at www.caresearch.com.au/caresearch/pcc4u/tabid/2083/Default.aspx.
  14. Kristjanson L, Lobb E, Aoun S, Monterosso L. A systematic review of the literature on complicate grief. Churchlands: Western Australian Centre for Cancer and Palliative Care, Edith Cowan University; 2006.
  15. National Center for Complementary and Alternative Medicine. What is complementary and alternative medicine? National Institutes of Health; 2011. Available at http://nccam.nih.gov/health/whatiscam.
  16. Natural Medicines Database. Available at www.naturaldatabase.com.
  17. The Royal Australian College of General Practitioners. Medical care of older persons in residential aged care facilities. 4th edn. Melbourne: The RACGP; 2006

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