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QMUL Medical student teaching

QMUL Medical student teaching. Dr Hattie Roebuck Consultant in Palliative Medicine Honorary Clinical Lecturer QMUL. Outline. National developments in Palliative Care GMC Curriculum requirements on End of Life Care Current palliative care curriculum at QMUL Suggestions. Background.

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QMUL Medical student teaching

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  1. QMUL Medical student teaching Dr Hattie Roebuck Consultant in Palliative Medicine Honorary Clinical Lecturer QMUL

  2. Outline • National developments in Palliative Care • GMC Curriculum requirements on End of Life Care • Current palliative care curriculum at QMUL • Suggestions

  3. Background • UK population becoming more elderly • 1 in 3 hospital pts are in last year of life • FY1’s will care for 40 dying patients & 120 in the last year of life • Clark D Palliative Medicine May 2014 • Jane Gibbins et al ‘Why are newly qualified doctors unprepared to care for patients at the end of life?’ • Qualitative study with 21 doctors at end of FY1 from 17 medical schools – interviewed till saturation of themes • Medical Education Journal 2011; 45: 389-399

  4. ‘I don’t remember being taken to see dying pts… you’re taken to see people with signs…That’s the thing with a medical student, ‘This person has got really good signs’, not ‘this person is dying go and see them’. • ‘they tried to drum into us what palliative care was about, but not how to do it…. Which hasn’t helped me as a new doctor in the middle of the night’ • Not all consultants/registrars know how to do EOLC – FY1’s learn this themselves, often from nurses or palliative care teams, learn on the job

  5. Liverpool Care Pathway Misuse • Liverpool care pathway discredited • More Care Less pathway • -> One Chance to get it Right • Francis report • Embedding common values and culture • Putting the patient first • Caring for the elderly • Caring compassionate & considerate nursing

  6. One Chance to Get it Right. When it is thought that a person may die within the next few days or hours, the five Priorities for Care are: • This possibility is recognised and communicated clearly, decisions made and actions taken in accordance with the person's needs and wishes, and these are regularly reviewed and decisions revised accordingly. • Sensitive communication takes place between staff and the dying person, and those identified as important to them. • The dying person, and those identified as important to them, are involved in decisions about treatment and care to the extent that the dying person wants. • The needs of families and others identified as important to the dying person are actively explored, respected and met as far as possible. • An individual plan of care, which includes food and drink, symptom control and psychological, social and spiritual support, is agreed, co-ordinated and delivered with compassion

  7. Changes to the law regarding DNACPR

  8. Changes to the law regarding DNACPR • Legal obligation to discuss • Recent court case regarding care given to Janet Tracey • Not informed of DNACPR decision -> engaged Article 8 of European convention of Human rights (Right to respect for Private & Family Life) • ‘Doctors should be wary of being too ready to exclude patients from discussions due to possible distress – would need to feel harm would occur’ • However, if CPR will not work, the patient cannot require a doctor to provide CPR.

  9. Background • 75% of UK deaths due to non-malignancy • Are those with a poor prognosis identified? • Identification allows patients and their families to prepare, referral to palliative care made, advance care plans to be developed • Pts with cancer & non cancer illness in last year of life are likely to be symptomatic

  10. Identifying exactly when death will occur hard especially in non malignancy • But several clinical tools are available that use indicators that can suggest poor prognosis

  11. Symptom prevalence in advanced disease(Solano, Gomes & Higginson, Journal Pain & Symptom management. Jan 06) • Cancer • Pain 35-96% • Confusion 6-93% • Anorexia 30-92% • Fatigue 32-90% • Anxiety/depression 3-79% • Dyspnoea 10-70% • Insomnia 9-69% • Nausea 6-68% • Cardiac failure • Dyspnoea 60-88% • Fatigue 69-82% • Pain 41-77% • Anxiety/depression 9-49% • Insomnia 36-48% • Nausea 17-48% • Constipation 38-42% • Anorexia 21-41%

  12. Advance care planning Different forms of advance care plans: • Preferred Place of Care, Preferred Place of Death • Advance Statement of Wishes (values, priorities) • Advance Decision to Refuse Treatment • Decisions regarding resuscitation • Lasting Power of Attorney Advance care plans only come into effect when patient has lost capacity Differs from care planning in that it anticipates a deterioration in the patients health

  13. What about the Medical students

  14. What about the Medical students ? • 5% of medical students will have had a significant bereavement in the past year • Equates to 25% over the course of time at med school

  15. What about the Medical students • GMC Tomorrows doctors • 14 Contribute to the care of patients and their families at the end of life, including the management of symptoms, practical issues of law & certification, and using effective communication and team working • GMC Preparedness for practice report 2014 • Potential weakness in preparedness of FY1s in: • End of Life Care, communication skills, and involving patients and families in decision making

  16. Current QMUL Core Palliative Care Teaching

  17. Current QMUL Core Palliative Care Teaching • Year 2 – Lecture ‘What is palliative care?’ • Year 3 • Death & Dying morning – Lecture: sociology of death • Lecture on bereavement • Expert panel • Oncology Hospice half day • Lecture: Explaining hospice & palliative care services • MDT Speed date • Lecture: Nausea & Vomiting • Goldfish bowl

  18. Year 4 • Lecture: Symptom control in the dying patient • Healthcare of Elderly firm – palliative care teaching being developed

  19. Year 4 • Lecture: Symptom control in the dying patient • Healthcare of Elderly firm – palliative care teaching Year 5 • Hospice half day • Lecture: Recognising & managing dying • Lecture: Pain management • Task based / simulated tutorials: managing a dying pt. • Communication skills teaching Breaking bad news • Palliative care prescribing teaching

  20. Tomorrows Doctors 2009 • Contribute to the care of patients & families at the end of life, including symptom management, practical issues of law & certification, & effective communication & teamwork (page 21) • Plan appropriate drug therapy for common indications including pain & distress (page 23) • Respond to patients’ concerns & preferences, & respect the right of patients to reach decisions with their doctor about their treatment & care and to refuse or limit treatment (page 20) • Discuss adaption to major life changes such as bereavement (page 15) • Provide a safe & legal prescription for medications & calculate appropriate doses (pg 23) • Access reliable information about medicines (pg 23)

  21. Suggestions for GP teaching topics

  22. Suggestions for GP teaching topics • Year 3 • Case Reflection –meet patient/ family. Take history, reflect on impact on pt/ family, impact on student, learning – what will take to future cases • Roles of MDT– DN/ GP/ inpatient hospice/ community palliative care nurse • Identification of those in last year of life - SPICT tool, attend GSF meetings / frail elderly MDTs, role of advance care planning • ?? Ethnic diversity

  23. Suggestions for GP teaching topics • Year 5 • www.pallied.com • Meeting palliative/ EOLC pts • Managing a death in community • Practice at writing: • DNACPR • Death certification • Controlled drug prescription • Safe use of opioids

  24. Summary • UK population getting older • All doctors need to know how to deliver palliative care • Students may not get the opportunity to meet dying patients • Identifying poor prognosis enables better care • Significant proportion of students bereaved • Increased GMC focus on end of life care teaching

  25. Suggestions for GP teaching topics • Year 3 • Case Reflection –meet patient/ family. Take history, reflect on impact on pt / family, impact on student, learning – what will take to future cases • Roles of MDT– DN/ GP/ inpatient hospice/ community palliative care nurse • Identification of those in last year of life - SPICT tool, attend GSF meetings / frail elderly MDTs, role of advance care planning • ?? Ethnic diversity • Year 5 • www.pallied.com • Meeting palliative/ EOLC pts • Managing a death in community • Practice at writing: • DNACPR • Death certification • Controlled drug prescription • Safe use of opioids

  26. Any questions, comments, suggestions?

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