Translate this page into:
Development of a Consensus Syllabus of Palliative Medicine for Physicians in Japan Using a Modified Delphi Method
This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms.
This article was originally published by Medknow Publications & Media Pvt Ltd and was migrated to Scientific Scholar after the change of Publisher; therefore Scientific Scholar has no control over the quality or content of this article.
Abstract
Context:
Although palliative care is rapidly being disseminated throughout Japan as a result of government policy, a systematic syllabus of palliative medicine for physicians has not been developed.
Aims:
This study aimed to develop a Japanese national consensus syllabus of palliative medicine for physicians.
Design:
We used a modified Delphi method to develop the consensus syllabus.
Methods and Setting:
We created a Delphi panel by selecting 20 expert eligible panelists consisting of Diplomate or Faculty of the Specialty Board of Palliative Medicine and certified by the Japanese Society for Palliative Medicine. We inducted external reviewers from 11 palliative care-related organizations.
Results:
Among 20 experts surveyed, 20 (100%) responded over all rounds. Ten (50%) participated in a panel meeting. In the first round, 179 of 179 (100%) learning objectives were judged to be appropriate and 5 of 179 (3%) learning objectives were judged to be too difficult. In the panel meeting, 25 learning objectives were excluded, three new learning objectives were added, and 15 learning objectives were reworded. In the second round, 18 of 18 (100%) learning objectives were judged to be appropriate. The final version of the syllabus developed consists of 157 specific behavioural objectives and 22 general instructional objectives across 22 courses.
Conclusions:
We have developed the first national consensus syllabus of palliative medicine for physicians in Japan. Based on this syllabus, a training program on palliative medicine will be established by training facilities in Japan, and physicians will be able to practice specific palliative care.
Keywords
Curriculum
Delphi method
education
palliative medicine
syllabus
INTRODUCTION
Improvement in palliative care is an important public healthcare issue worldwide.[1] According to the World Health Organization, palliative care aims to improve the quality of life of patients and families who face life-threatening illness, by providing pain and symptom relief, spiritual, and psychosocial support from the diagnosis to end-of-life care, and support during bereavement. Further, the WHO recommends that palliative care should become an integral part of healthcare and that all patients affected by a life-threatening disease should have access to palliative care services. This statement is further supported by the European Association of Palliative Care[2] and is also in agreement with the European Council's guidelines for the European Union member states.[3] This consensus in favor of integrating palliative care within regular treatment offered to patients with life-threatening disease is supported by a growing amount of evidence indicating the effectiveness of palliative care in improving quality of life of these patients.[456]
The Cancer Control Act was implemented in 2007 in Japan and emphasized the importance of the early introduction of appropriate palliative care to maintain and improve patient quality of life over the course of illness; however, palliative care is yet to become sufficiently widespread throughout Japan. One of the reasons suggested for this is the lack of appropriate education and support systems enabling the implementation of basic palliative care.[7] In Japan, it has been reported that only approximately 20% of physicians responded that they “received sufficient education regarding palliative care” and only approximately 30% responded that they had “sufficient knowledge and skills regarding alleviation of symptoms.” Both of these figures are much lower than those reported in Western countries.[891011]
The training curriculum of palliative medicine in Japan comprises the “Training Curriculum for Physicians Aiming to Become Palliative Care Specialists” developed by the Japanese Society for Palliative Medicine in 2009, which is based on the curriculum for multiple disciplines developed by the Japan Hospice Palliative Care Association.[12] However, it has been reported that specialized palliative care training programs are required and that learning methods for acquiring specialized knowledge remain insufficient.[13] Therefore, in accordance with clinical needs and to respond to the demands of physicians studying palliative medicine, it appears necessary to revise the training curriculum for physicians.
In this study, we aimed to clarify the essential learning outcomes in palliative care that physicians aiming to become palliative medicine specialists should achieve by the time they graduate from the training program. We used a modified Delphi method,[14] which is widely used to in developing educational syllabuses.[151617181920]
SUBJECTS AND METHODS
We adopted a modified Delphi method[14] to develop a consensus syllabus of palliative medicine for physicians.
Development of a provisional syllabus
To develop a provisional syllabus, we adopted the following procedures. First, the authors established the structure and sections of the syllabus based on discussions and literature review.[121920212223242526272829] Second, one author (A. S.) generated an item pool of learning outcomes under each category of the syllabus based on a literature review. Third, the authors discussed the appropriateness and coverage of the item pool of learning outcomes to reach a consensus regarding their validity, and the provisional syllabus was then formulated.
Expert panel selection
We selected expert and eligible panelists to create a Delphi panel that consisted of Diplomate or Faculty of the Specialty Board of Palliative Medicine and certified by the Japanese Society for Palliative Medicine. We contacted the Japanese Society for Palliative Medicine through mail and asked them to participate in this study and recommend panelists based on the following criteria: (1) physicians with adequate experience as part of a palliative care consultation team; (2) physicians with adequate experience at a palliative care unit; (3) physicians with adequate experience in community-based palliative care; and (4) coordinators of palliative care education at a university-level graduate school of medicine. Each group consisted of five expert panelists, making a total number of 20 expert panelists. All individuals who confirmed that they met the eligibility criteria and expressed a willingness to participate were included in the Delphi study. The study was conducted in accordance with the Declaration of Helsinki and ethical guidelines with regard to clinical research. This study was reviewed by the Institutional Review Board at Hyogo Prefectural Kakogawa Medical Center, which approved it with waiver of informed consent.
Survey process
Google Forms™ was used to conduct anonymous web-based surveys during the period from September 2016 to March 2017. Our Delphi study consisted of three rounds, each lasting 4 weeks with a 4-week gap between the rounds. Nonrespondents were sent weekly E-mail reminders. No financial incentives were provided.
First, each panelist was asked to review existing syllabi and literature to standardize their knowledge regarding learning outcomes in palliative medicine education for physicians.
Second, 4 weeks later, we implemented a first-round survey, mailing a questionnaire with the outline of the provisional learning outcomes to each panelist. Each member was asked to rate the appropriateness of each learning outcome using a nine-point Likert-type scale (inappropriate 1–3, intermediate 4–6, and appropriate 7–9). In cases where panelists were unfamiliar with items due to their specialty, an “incapable of rating” result was also generated. Panelists, who rated a statement with a score of <6, were asked to provide the reason. In addition, each member was asked to rate the difficulty in each learning outcome using a four-point Likert-type scale: 0 (easy), 1 (adequate), 2 (moderately difficult), 3 (too difficult), and the learning outcomes were reformulated to be more achievable as needed. Panelists who rated the outcome difficulty as 2 or 3 were asked to provide the reason. A consensus in this study was defined a priori as agreement (appropriate, 7–9) among a minimum of 75% of the experts. We also collected basic demographic information from the experts including age, gender, type of clinical practice, and years of experience. A summary of the first-round survey was sent to each panelist and author, and disagreements were discussed via E-mail over 2 weeks. We asked the panelists, especially those who would not be able to attend a panel meeting, to provide their opinions.
Third, we contacted 11 palliative care-related organizations [Table 1] through mail-in December 2016 and asked them to participate in the study and to recommend a representative in charge of education in palliative medicine as an external reviewer. We mailed them the provisional syllabus, summary of the first-round survey, and description of each panelist. We requested opinions regarding the provisional syllabus and each learning outcome from the external reviewers.
| Hospice palliative care japan |
| Japan Primary Association |
| Japan Psycho-Oncology Society |
| Japan Society of Clinical Oncology |
| Japan Federation of Cancer Patient Groups |
| Japanese Society of Cancer Nursing |
| Japanese Society of Medical Oncology |
| Japanese Society for Palliative Medicine |
| Japanese Society of Pharmaceutical Palliative Care and Sciences |
| The Japanese Academy of Home Care Physicians |
| The Japanese Association for Clinical Research on Death and Dying |
Fourth, following discussions through E-mail, an expert panel meeting was convened on December 24, 2016, in Tokyo to discuss statements causing disagreement in person. At the meeting, a summary of the first-round survey, discussion through E-mail, and opinions from the external reviewers were distributed. Following the panel meeting, a summary of the meeting and a revised version of the learning outcomes were sent to all panelists to confirm corrections or to determine whether there were additional opinions.
Fifth, we implemented a second-round survey using the same method as in the first-round survey, addressing only the learning outcomes that could not be agreed on in the first-round survey. For learning outcomes considered inappropriate, the relevant panelists were contacted via E-mail individually, and we attempted to reach an agreement.
Sixth, we conducted a third-round survey using the same methods as in the first-and second-round surveys, addressing only the learning outcomes that could not be agreed upon in the first-and second-round surveys. We eliminated learning outcomes that could not be agreed on during the third round.
Statistical analysis
Data analysis was performed using the software Statistical Package for Social Science version 22.0 (SPSS Japan, Tokyo, Japan).
RESULTS
Participant characteristics
The participants’ characteristics are summarized in Table 2. Among 20 experts surveyed, 20 (100%) responded over all rounds. Ten (50%) participated in a panel meeting.
| n (%) | |
|---|---|
| Sex | |
| Male | 11 (55) |
| Female | 9 (45) |
| Age | |
| 30-39 | 4 (20) |
| 40-49 | 10 (50) |
| 50-59 | 6 (30) |
| Clinical experience (years) | |
| 10-19 | 10 (50) |
| 20-29 | 9 (45) |
| ≥30 | 1 (5) |
| Clinical experience in palliative care of more than 5 years | 18 (90) |
| Experience in palliative care education of more than 5 years | 14 (70) |
First Delphi round
In the first-round survey, 179 of 179 (100%) learning objectives were judged to be appropriate by more than 75% of the respondents, and 5 of 179 (3%) learning objectives were judged to be too difficult by more than 10% of the respondents.
In the panel meeting, all learning objectives were examined carefully. Subsequently, 3 new learning objectives were added, and 25 learning objectives were excluded, owing to their high difficulty, during the panel meeting. In case of satisfactory statements that included correcting modes of expression, shuffling of learning objectives among courses, and binding similar objectives together, we made revisions based on a discussion among the participants and authors. In addition, we reworded 15 learning objectives judged to be difficult to make them more understandable and achievable. The number of learning objectives was 157 across 22 courses after the panel meeting. Following the panel meeting, a summary of the panel meeting and a revised version of the learning objectives were sent to all panelists to confirm corrections or determine whether there were additional opinions. We revised them based on a discussion among authors, resulting in 18 learning objectives being reworded, and then conducted the second Delphi round.
Second Delphi round
In the second-round survey, all panelists responded with 18 of 18 (100%) learning objectives judged to be appropriate by more than 75% of the respondents. No learning objectives were rated to be unnecessary or unimportant by more than 75% of the respondents. We decided to conclude the Delphi rounds after the second-round survey because most of the stated learning outcomes had achieved consensus. The final version of the syllabus [Appendix] consists of 157 specific behavioral objectives and 22 general instructional objectives across 22 courses [Table 3].
| Courses | General instructional objectives |
|---|---|
| Comprehensive assessment | To be able to holistically understand patients and comprehend both patients’ pain and what constitutes support for these individuals |
| Pain management | To be able to assess patients’ pain and use pharmacotherapy as well as other methods, including nonpharmacological therapy to alleviate pain |
| Management of physical symptoms other than pain | To be able to evaluate symptoms other than pain and use pharmacotherapy and various other methods including nonpharmacological therapy to alleviate these symptoms |
| Management of psychiatric symptoms | To be able to evaluate psychiatric symptoms and use pharmacotherapy and various other methods, including nonpharmacological therapy to alleviate these symptoms |
| Palliative care of noncancer illnesses | To be able to cooperate with specialists to investigate the indications for palliative care for patients with noncancer illnesses and provide appropriate palliative care |
| Psychological reaction | To be able to evaluate psychological reactions and respond appropriately |
| Social issues | To be able to evaluate social issues and respond appropriately |
| Spiritual care | To be able to accurately understand patients’ spiritual pain and offer appropriate support |
| Ethical issues | To be able to understand ethical issues associated with palliative care and respond appropriately |
| Decision-making support | To be able to support decision-making while considering the wishes of the patients and their families |
| Communication | To be able to engage in communication while considering patients’ personalities |
| Palliative sedation | To be able to implement appropriate sedation to relieve otherwise intolerable suffering for patients |
| Disease trajectory | To be able to understand the disease trajectory and predict the prognosis |
| Care of dying patients | To be able to respond appropriately to patients in the end stages of their lives as well as to their families |
| Family care | To be able to notice challenges faced by patients’ families and implement appropriate care for them |
| Bereaved family care | To be able to notice reactions of grief to bereavement and loss and respond appropriately |
| Psychological care for healthcare providers | To be able to provide psychological care for oneself and staff |
| Team work in medicine | To be able to practice medicine as a team |
| Consultation | To be able to provide appropriate consultations regarding palliative care |
| Regional coordination | To be able to coordinate with regional medical facilities and provide medical care appropriate for each region |
| Oncology | To acquire knowledge of oncology and be able to offer the best medical options for the patient |
| Education and research | To be able to contribute to the development of palliative care by being involved in education and research as well as constantly updating knowledge as a palliative care specialist |
Third Delphi round
We concluded the study with the third-round survey, and no further Delphi round because all of the stated learning outcomes had achieved consensus after the second-round survey.
DISCUSSION
To the best of our knowledge, this study generated the first consensus syllabus of palliative medicine for physicians developed using a modified Delphi method.
The most important finding was that we used innovative processes to develop the syllabus. First, based on the modified Delphi method, we used E-mail discussion and panel meetings between the first and the second rounds of our Delphi study. The participants discussed backgrounds and reasons for their ratings of each learning objective and shared their opinions with each other, with the aim of making the learning objectives more adequate and achievable. Second, in the survey on the provisional syllabus and the first Delphi round, we evaluated the degree of difficulty for each learning outcome. In general, while developing the syllabus, learning objectives tended to increase in number during the process. We subsequently discussed and rewrote the objectives rated as too difficult by more than 10% of the panelists to make them more achievable and understandable. Third, external reviewers enabled us to be indirectly aware of perspectives from patients, families, and other disciplines, leading to a wider range of opinions regarding the syllabus. Subsequently, 25 learning objectives were excluded and three learning objectives were added. We surmise that these same three innovative processes undertaken to develop the educational syllabus on palliative care could also be adapted for other medical specialties, and indeed for any investigations using a Delphi method.
The second important result of the present study was that palliative care of noncancer illnesses was added as learning objectives. Although palliative care is rapidly being disseminated throughout Japan as a result of government policy,[7] palliative care is not provided for illnesses other than cancer. In the year 2007, the Cancer Control Act and the Basic Plan to Promote Cancer Control Programs were enacted in Japan, addressing palliative care as one of the major issues in improving cancer care. This program required all government-designated cancer-care hospitals to organize hospital-based palliative care teams within each institute. However, it was pointed out that palliative care continues to be primarily intended for cancer patients and is less accessible to those with other illnesses, compared to the situation in Western countries.[30] The syllabus developed here may also be useful as an audit tool. Several institutions have developed palliative medicine curricula and may not wish to extensively revamp them. The syllabus might be used as a benchmark to compare their own programs with a national syllabus produced by an expert body of opinion or to assess the effectiveness of palliative care teaching in institutions.
This study has several limitations. First, the E-mail discussion and the panel meeting between the two Delphi rounds did not protect the anonymity of an individual's views, which might have affected the ratings during the second Delphi round, although the Delphi round itself retained its anonymity. Second, we only surveyed physicians in this study. Experts in other disciplines and patients may have different perspectives that would need to be explored in future studies. The syllabus might not reflect user or consumer perspectives sufficiently because of the panel selection process used. We aimed to overcome this limitation by seeking opinions of external reviewers that enabled us to gather a wider range of opinions regarding the syllabus. It might be useful to also conduct separate focus groups or external reviews involving patients, bereaved families, trainees, or experts in other disciplines. Third, we only surveyed learning objectives in our study. The education curriculum comprises learning objectives, educational strategies, implementation, and evaluation. Further, we need to examine educational strategies, and implementation and evaluation of training programs on palliative medicine.
CONCLUSIONS
We developed a consensus syllabus of palliative medicine for physicians using a systematic methodology. Based on this syllabus, a training program on palliative medicine will be established by training facilities in Japan, and all physicians will be able to practice specific palliative care. Subsequent steps will involve implementation of this program and assessment of whether this syllabus achieves the desired endpoint, which is enabling qualified physicians with broad knowledge and understanding of the principles and practice of palliative medicine.
Financial support and sponsorship
This study was funded by the Japanese Society for Palliative Medicine.
Conflicts of interest
There are no conflicts of interest.
Acknowledgments
The authors would like to thank all participants and participating institutions for taking part in this study.
REFERENCES
- World Health Organization: Definition of Palliative Care. Available from: http://www.who.int/cancer/palliative/definition/en/
- White Paper on standards and norms for hospice and palliative care in Europe: Part 1 recommendations from the European association for palliative care. Eur J Palliat Care. 2009;16:278-89.
- [Google Scholar]
- 2003. Council of Europe. Recommendation Rec 24 of the Committee of Ministers to Member States on the Organization of Palliative Care. Available from: http://www.eapcnet.eu/LinkClick.aspx?fileticket=3KJ5U3BQLVY%3d&tabid=1709
- Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med. 2010;363:733-42.
- [Google Scholar]
- Early versus delayed initiation of concurrent palliative oncology care: Patient outcomes in the ENABLE III randomized controlled trial. J Clin Oncol. 2015;33:1438-45.
- [Google Scholar]
- End-of-life care pathways for improving outcomes in caring for the dying. Cochrane Database Syst Rev. 2013;11:CD008006.
- [Google Scholar]
- 2007. Ministry of Health, Labor, and Welfare: Basic Plan to Promote Cancer Control Programs. Available from: http://www.mhlw.go.jp/bunya/kenkou/gan_keikaku.html
- European Society of Medical Oncology Taskforce on Palliative and Supportive Care. Attitudes of medical oncologists toward palliative care for patients with advanced and incurable cancer: Report on a survery by the European Society of Medical Oncology Taskforce on palliative and supportive care. Cancer. 2003;98:2502-10.
- [Google Scholar]
- Knowledge and attitudes of health-care providers toward cancer pain management: A comparison of physicians, nurses, and pharmacists in the state of New Hampshire. J Pain Symptom Manage. 1998;15:335-49.
- [Google Scholar]
- A UK-wide postal survey to evaluate palliative care education amongst general practice registrars. Palliat Med. 2006;20:463-9.
- [Google Scholar]
- Practices and attitudes of Japanese oncologists and palliative care physicians concerning terminal sedation: A nationwide survey. J Clin Oncol. 2002;20:758-64.
- [Google Scholar]
- Hospice Palliative Care Japan: curriculum for Multiple Disciplines. Available from: https://www.hpcj.org/med/ed_cur.html
- Unmet learning needs of physicians in specialty training in palliative care: A Japanese nationwide study. J Palliat Med. 2016;19:1074-9.
- [Google Scholar]
- The RAND/UCLA Appropriatenss Method User's Manual. 2001109.
- [Google Scholar]
- Educational objectives for medical training in the care of the terminally ill. Acad Med. 1994;69:688-90.
- [Google Scholar]
- Palliative care curriculum development: A model for a content and process-based approach. J Palliat Med. 2002;5:539-48.
- [Google Scholar]
- Educational program in palliative and hospice care at the university of Maryland school of medicine. J Cancer Educ. 1996;11:144-7.
- [Google Scholar]
- The Canadian palliative care undergraduate curriculum. J Cancer Educ. 1993;8:197-201.
- [Google Scholar]
- A Delphi study to develop the association for palliative medicine consensus syllabus for undergraduate palliative medicine in Great Britain and Ireland. Palliat Med. 2008;22:360-4.
- [Google Scholar]
- Development of a nationwide consensus syllabus of palliative medicine for undergraduate medical education in Japan: A modified Delphi method. Palliat Med. 2012;26:744-52.
- [Google Scholar]
- End-of-life care in the curriculum: A national study of medical education deans. Acad Med. 2004;79:760-8.
- [Google Scholar]
- Outcomes from a national multispecialty palliative care curriculum development project. J Palliat Med. 2007;10:408-19.
- [Google Scholar]
- A syllabus for fellowship education in palliative medicine. Am J Hosp Palliat Care. 2003;20:279-89.
- [Google Scholar]
- The Japanese Society for Palliative Medicine: ‘Curriculum for Physicians in Palliative Medicine’; 2009. Available from: http://www.jspm.ne.jp/nintei/senmon/curriculum.pdf
- [Google Scholar]
- Ministry of Education, Culture, Sports, Science and Technology: ‘Medical Education Model Core Curriculum (2016 Revised Version) Available from: http://www.mext.go.jp/component/b_menu/shingi/toushin/__icsFiles/afieldfile/2017/06/28/1383961_01.pdf
- [Google Scholar]
- The European Association for Palliative Care: For the Development of Postgraduate Curricula Leading to Certification in Palliative Medicine. Available from: http://www.eapcnet.eu/LinkClick.aspx?fileticket=2DHXbM1zaMI%3d
- [Google Scholar]
- The European Association for Palliative Care: Curricula in Palliative Care for Undergraduate Medical Education. Available from: http://www. eapcnet.eu/LinkClick.aspx?fileticket=VmnUSgQm5PQ%3d
- [Google Scholar]
- Joint Royal Colleges of Physicians Training Board: Specialty Training Curriculum for Palliative Medicine. 2010. (Amendments 2014) Available from: https://www.jrcptb.org.uk/sites/default/files/2010%20Palliative%20medicine%20%28amendments%202014%29.pdf
- [Google Scholar]
- The Royal College of General Practitioners: Palliative and End of Life Care Toolkit. Available from: http://www.rcgp.org.uk/clinical-and-research/toolkits/palliative-and-end-of-life-care-toolkit.aspx
- [Google Scholar]
- The 2015 Quality of Death Index. Ranking Palliative Care Across the World. A Report by the Economist Intelligence Unit. Available from: https://www.eiuperspectives.economist.com/sites/default/files/images/2015%20Quality%20of%20Death%20Index%20Country%20Profiles_Oct%206%20FINAL.pdf
- [Google Scholar]
APPENDIX
Japanese Society for Palliative Medicine
Palliative Specialist
Training Curriculum
2017 Edition
Contents
Introduction 3
Curriculum development process Subjects Trainers and training facilities Qualities and Attitude of Physicians Implementing Palliative Care 4 Training Items 5
INTRODUCTION
Development of this curriculum
The Cancer Control Act was implemented in 2007 in Japan and stated the importance of the early introduction of appropriate palliative care to maintain and to improve the patient's quality of life (QOL) over the course of their illness; however, palliative care is yet to become sufficiently widespread throughout Japan. One of the suggested reasons for this is the lack of appropriate education and support systems to enable the implementation of basic palliative care. In Japan, it has been reported that only approximately 20% of physicians responded that they “received sufficient education regarding palliative care” and only about 30% responded that they had “sufficient knowledge and skills regarding alleviation of symptoms.” Both of these figures are much lower than the results found in western countries. The training curriculum for palliative medicine in Japan comprises the “Training Curriculum for Physicians Aiming to Become Palliative Care Specialists” developed by the Japanese Society for Palliative Medicine in 2009 based on the curriculum for multiple disciplines developed by the Japan Hospice Palliative Care Association. However, it has been reported that specialized palliative care training programs are required and that learning methods for acquiring specialized knowledge remain insufficient. Thus, in accordance with clinical needs and to respond to the demands of physicians studying palliative medicine, it appears necessary to revise the “Training Curriculum for physicians Aiming to Become Palliative Care Specialists.” Therefore, the Working Practitioner Group (WPG) for Specialist Curriculum Planning, Committee on Education and Training in the Japanese Society for Palliative Medicine decided to establish a 2017 Palliative Specialist Training Curriculum.
When setting the training goals, a portfolio used for business and medical education in recent years was used as a reference to respond to the needs of physicians undergoing training in various situations. For the actual training, the trainee will generally set the objectives and strive to achieve them while confirming the progress with the trainer. Although record taking is somewhat complex, it is anticipated that it will aid the communication between the trainee and trainer as well as with the other staff in the palliative care.
Subjects
This curriculum is meant for physicians aiming to become palliative care specialists.
Trainers and training facilities
Trainers: Diplomate or Faculty (tentative), Specialty Board of Palliative Medicine certified by the Japanese Society for Palliative Medicine Training facilities: Institute, Specialty Board of Palliative Medicine, certified by the Japanese Society for Palliative Medicine.
QUALITIES AND ATTITUDE OF PHYSICIANS IMPLEMENTING PALLIATIVE CARE
Definition of palliative care: Palliative care is a type of care that is provided in cooperation with professionals in medical and welfare fields as well as various other disciplines over the entire course of the illness regardless of the place of end-of-life care to improve the QOL of patients with life-threatening and difficult to cure diseases and their families. Palliative care is provided so that the patients and their family can live in an as dignified and comfortable manner as possible. The following five items are required for palliative care:
Alleviate pain and other distressing symptoms Provide high regard to human life and pay respect to the “course of death,” which all people will experience Do not unnaturally prolong life in a manner not desired by the patients or their family and do not intentionally cause death Offer mental and social support as well as spiritual care and help the patients live their life positively until the end Help the family to overcome various difficulties throughout the course of patients’ illnesses and after they die.
Physicians should understand that palliative care aims to maintain and/or improve patients’ QOL regardless of their life expectancy. Due to the needs of patients and their families are constantly changing, which in turn causes their care objectives to change, constant review is necessary All patients live various lives before facing death. Rather than simply viewing illness as a disease, physicians should place importance on what significance the illness has in that person's life (i.e., the meaning of the illness). Physicians must view the patient and their family holistically by understanding them mentally, socially, and spiritually rather than just physically Physicians should understand that the care must be offered not only to patients but also to the people surrounding them Physicians should understand that what is comfortable for the patient differs greatly amongst individuals, and importance should be placed on patient autonomy and choice Although the most important requirements of physicians who implement palliative care is excellent medical judgment and skills as a physician, they also need to be able to communicate well. Good communication with patients and their families and among medical team members is required It is critical that physicians offer sufficient explanations of medical care and obtain informed consent from patients and their families based on such knowledge. If necessary, consideration should be given to a second opinion Physicians should work as a member of the palliative care team. They must respect the specialty and opinion of each team member and constantly strive to help the team operate smoothly.
TRAINING ITEMS
The training objectives for physicians aiming to become palliative care specialists have been divided into the following items and presented below:
General Instructional Objectives (GIOs): Each patient's suffering is understood as holistic one (total pain). Palliative care is implemented to improve the QOL of the patients and their families and acquire the ability to provide education and conduct clinical research in this field.
COURSE LIST
Course 1: Comprehensive assessment GIO: To be able to holistically understand the patients and comprehend both patients’ pain and what constitutes support for these individuals. Course 2: Pain management GIO: To be able to assess patients’ pain and use pharmacotherapy as well as other methods, including nonpharmacological therapy, to alleviate pain. Course 3: Management of physical symptoms other than pain GIO: To be able to evaluate symptoms other than pain and use pharmacotherapy and various other methods, including nonpharmacological therapy, to alleviate these symptoms. Course 4: Management of psychiatric symptoms GIO: To be able to evaluate psychiatric symptoms and use pharmacotherapy and various other methods, including nonpharmacological therapy, to alleviate these symptoms. Course 5: Palliative care of noncancer illnesses GIO: To be able to cooperate with specialists to investigate the indications for palliative care for patients with noncancer illnesses and provide appropriate palliative care. Course 6: Psychological reaction GIO: To be able to evaluate psychological reactions and respond appropriately. Course 7: Social issues GIO: To be able to evaluate social issues and respond appropriately. Course 8: Spiritual care GIO: To be able to accurately understand patients’ spiritual pain and offer appropriate support. Course 9: Ethical issues Course 10: Decision-making support GIO: To be able to support decision-making while considering the wishes of the patients and their families. Course 11: Communication GIO: To be able to engage in communication while considering patients’ personalities. Course 12: Palliative sedation GIO: To be able to implement appropriate sedation to relieve otherwise intolerable suffering for patients. Course 13: Disease trajectory GIO: To be able to understand the disease trajectory and predict the prognosis. Course 14: Care of dying patients GIO: To be able to respond appropriately to patients in the end stages of their lives as well as to their families. Course 15: Family care GIO: To be able to notice challenges faced by patients’ families and implement appropriate care for them Course 16: Bereaved family care GIO: To be able to notice reactions of grief to bereavement and loss and respond appropriately. Course 17: Psychological care for healthcare providers GIO: To be able to provide psychological care for oneself and staff. Course 18: Team-work in medicine GIO: To be able to practice medicine as a team. Course 19: Consultation GIO: To be able to provide appropriate consultations regarding palliative care. Course 20: Regional coordination GIO: To be able to coordinate with regional medical facilities and provide medical care appropriate for each region. Course 21: Oncology GIO: To acquire knowledge of oncology and be able to offer the best medical options for the patient. Course 22: Education and research GIO: To be able to contribute to the development of palliative care by being involved in education and research as well as constantly updating knowledge as a palliative care specialist.
Specific Behavioral Objectives (SBOs):
Course 1: Comprehensive assessment GIO: To be able to holistically understand the patients and comprehend both patients’ pain and what constitutes support for these individuals. SBOs:
To be able to describe the concept of total pain To be able to understand patients’ pain from multiple facets To be able to list management plans for various types of pain To be able to understand a diverse range of elements, including patients’ wishes, beliefs, and values and construct treatment objectives in accordance with patients’ wishes To be able to detect pain quickly and provide appropriate treatment and prevention. Course 2. Pain management GIO: To be able to assess patients’ pain and use pharmacotherapy as well as various other methods, including a nonpharmacological therapy, to alleviate pain. SBOs:
To be able to describe the definition of pain To be able to describe the causes and mechanisms of pain To be able to describe pain assessment in specific terms To be able to explain the types of pain and typical pain syndrome To be able to explain the World Health Organization (WHO) Cancer Pain Relief Program in specific terms To be able to explain neuropathic pain To be able to describe care for pain To be able to appropriately select pharmacotherapy for pain in accordance with the WHO Cancer Pain Relief Program To be able to appropriately select opioids in accordance with patients’ conditions To be able to select adjuvant analgesic drugs, if necessary To be able to appropriately administer drugs orally and by other means To be able to appropriately prevent and treat any side effects caused by opioids To be able to understand and respond to a psychological opioid dependency To be able to consider radiation therapy indications and proceed with such therapy appropriately or consult with and/or refer to a specialist To be able to consider surgical treatment indications and proceed with such treatment appropriately or consult with and/or refer to a specialist To be able to consider nerve block indications and proceed with such treatment appropriately or consult with and/or refer to a specialist To be able to assess and respond to noncancer pain. Course 3: Management of physical symptoms other than pain GIO: To be able to evaluate physical symptoms other than pain and use pharmacotherapy and various other methods, including non-pharmacological therapy, to alleviate these symptoms. SBOs: To be able appropriately respond to the following conditions and diseases
Fatigue Anorexia Cachexia syndrome Nausea/vomiting Bowel obstruction Constipation Diarrhea Ascites Abdominal distention Hiccups Dysphagia Oral/esophageal candidiasis Stomatitis Dry mouth Jaundice Dypnea Cough Pleural effusion Excessive airway secretion Urinary incontinence Dysuria Oliguria/anuria Hydronephrosis (including indications for nephrostomy) Hematuria Bedsore Skin ulcers Pruritus Seizures Myoclonus Paralysis of the limbs and trunk Tremors/involuntary movements Delirium Edema Fever. Course 4. Management of psychiatric symptoms GIO: To be able to evaluate psychiatric symptoms and use pharmacotherapy and various other methods, including non-pharmacological therapy, to alleviate these symptoms. SBOs: To be able to appropriately respond to the following conditions and diseases:
Depression Adjustment disorders Anxiety Sleep disorders. Course 5: Palliative care of noncancer illnesses GIO: To be able to cooperate with specialists to investigate the indications for palliative care for patients with noncancer illnesses and provide appropriate palliative care. SBOs: To be able to cooperate with specialists to appropriately respond to the following illnesses:
Liver failure Respiratory failure Heart failure Kidney failure Neurological/muscular disorders Dementia Acquired immunodeficiency syndrome. Course 6: Psychological reaction GIO: To be able to evaluate psychological reactions and respond appropriately. SBOs:
To be able to recognize psychological reactions (e.g., denial and anger) and respond appropriately To be able to understand that grief and loss reactions are expressed in a variety of situations and in various ways and that this is an important process in healing sorrow To be able to consider psychological defense mechanisms. Course 7: Social issues GIO: To be able to evaluate social issues and respond appropriately. SBOs:
To understand social insurance systems (e.g., healthcare insurance system and nursing care insurance system) To be able to consider the social and economic issues faced by patients and their families To be able to consider issues occurred within the family To be able to appropriately refer to and use resources for the social and economic support of patients and their families. Course 8: Spiritual care GIO: To be able to accurately understand patients’ spiritual pain and offer appropriate support. SBOs:
To understand the main categories of spiritual pain To be able to respect the beliefs and values of the patients and their family in medical care To be able to recognize the importance of and the effects of views of life and death of the patients, their family, and healthcare providers on spiritual pain To be able to recognize the fact that spiritual pain as well as religious and cultural background greatly affect patients’ QOL To be able to respect patients’ and their families’ religious views on death. Course 9: Ethical issues GIO: To be able to understand ethical issues associated with palliative care and respond appropriately. SBOs:
To be able to describe basic ethical principles in medical care To be able to explain ethical issues in palliative care To be able to investigate ethical issues in palliative care based on ethical principles with multidisciplinary staff To be able to respect the right of the patients to refuse treatment and to obtain information regarding other treatment options To be able to respond appropriately with regards to stopping or withholding treatment To understand the status of social arguments on dignified death and euthanasia. Course 10: Decision-making support GIO: To be able to support decision-making while adhering to the wishes of the patients and their family SBOs:
To be able to describe the concept of Advance Care Planning To be able to discuss methods of treatment and care with the patients and their family and create treatment and care plans with them To be able to respect and give consideration to the thoughts and wishes of the patients and their family regarding treatment To be able to respect patient autonomy and offer decision-making support To be able to provide the necessary information for determining the location for end-of-life care and offer decision-making support. Course 11: Communication GIO: To be able to engage in communication while being considerate of patients’ personalities. SBOs:
To be able to understand patients’ communication and coping styles, respond appropriately, and offer support To be able to describe specific methods for conveying bad news to the patients and their families To be able to pay attention to non-verbal communication as well as verbal communication To be able to appropriately convey information pertaining to the diagnosis, prognosis, and treatment strategies to the patients To be able to listen to patients’ hopes, wishes, and values To be able to respond to difficult questions from the patients and expressions of emotion. Course 12: Palliative sedation GIO: To be able to implement appropriate sedation to relieve otherwise intolerable suffering for patients. SBOs:
To be able to describe the indications, limitations, and issues associated with sedation used to provide relief from intolerable distress To be able to explain sedation to the patients and their families and offer appropriate sedation when necessary To be able to respond appropriately to consultations regarding sedation from other healthcare providers To understand the status of social arguments on sedation. Course 13: Disease trajectory GIO: To be able to understand the disease trajectory and predict the prognosis. SBOs:
To be able to describe differences in trajectory specific to each disease To be able to understand prognosis prediction tools and also describe their limitations To be able to deliver appropriate explanations to the patients and their families based on prognosis prediction. Course 14: Care of dying patients GIO: To be able to respond appropriately to patients in the end stages of their life as well as their families. SBOs:
To be able to treat the patients as individuals and with respect when they are approaching death and even after death To be able to give consideration to the timing of end-of-life care and the family's psychological state immediately after the patient's death To be able to appropriately judge when it is time for end-of-life care To have sufficient knowledge regarding infusions in the terminal stages and be able to perform such infusions appropriately To be able to respect the wishes of the patients and their families and provide necessary instructions for end-of-life care in accordance with patients’ conditions To be able to appropriately explain necessary information before and after death to patients’ families. Course 15: Family care GIO: To be able to notice challenges faced by patients’ families and implement appropriate care for them. SBOs:
To be able to grasp the family background To be able to understand the communication and coping styles of members of patients’ families and respond appropriately To be able to consider the fact that each family member has different opinions and perspectives regarding the patient's condition and prognosis To be able to notice the sense of burden and fatigue of patients’ families and respond appropriately. Course 16: Bereaved family care GIO: To be able to notice reactions of grief in response to bereavement and loss and respond appropriately. SBOs:
To be able to describe grief reaction patterns to bereavement and loss To be able to describe conditions (risk factors) that are likely to cause complicated grief reactions To be able to notice anticipatory grief and respond appropriately To be able to support people who have experienced the bereavement To be able to notice complicated grief reactions and respond appropriately To be able to detect depression early and refer the person to a specialist. Course 17: Psychological care for healthcare providers GIO: To be able to provide psychological care for oneself and staff members. SBOs:
To be able to recognize one's own psychological stress and that of team members To be able to understand the importance of requesting help from other staff members for one's own psychological stress To be able to recognize the fact that one's personal opinions and views on death influence patients and staff members To be able to engage in team discussions and overcome feelings of guilt held by oneself or other staff about the possibility that care was inadequate To be able to learn about and implement staff support methodology To be able to understand that staff is constantly confronted with experiences of death and loss and distinguish normal psychological reactions and “burn-out” reactions. Course 18: Team-work in medicine GIO: To be able to practice medicine as a team. SBOs:
To be able to understand the importance and difficulty of team-work in medicine and function as a member of a team To be able to understand the importance of leadership and make efforts to improve the ability of team members To be able to understand functions of staff members and volunteers from other disciplines and display mutual respect To be able to describe basic group dynamics and their importance in team medicine. Course 19: Consultation GIO: To be able to provide appropriate consultations regarding palliative care. SBOs:
To be able to describe consultation opportunities To be able to provide appropriate recommendations and direct care in response to consultation requests To be able to consider the individuality of the patient and their family in recommendations and direct care and provide these recommendations based on treatment guidelines To be able to discuss the details of an assessment and recommendations with the requesting healthcare providers To be able to hold conferences with the requesting healthcare providers if necessary. Course 20: Regional coordination GIO: To be able to coordinate with regional medical facilities and provide medical care appropriate to each region. SBOs:
To be able to describe the roles in the region of one's affiliated organization To be able to collaborate with regional medical facilities to provide palliative care To be able to understand the status of regional medical and social resources To be able to offer support for transition to a location for end-of-life care desired by the patients and their families To be able to coordinate with healthcare providers involved in home care and offer consultations or implement home palliative care. Course 21: Oncology GIO: To acquire knowledge of oncology and to be able to offer the best medical options for the patient. SBOs:
To be able to acquire basic knowledge of oncology To be able to understand the indications for surgical treatment and appropriately consult with specialists To be able to understand the indications for radiotherapy and appropriately consult with specialists To be able to understand the indications for pharmacotherapy to treat cancer and appropriately consult with specialists To be able to cooperate with specialists to appropriately deal with the following oncological emergencies:
Hypercalcemia Syndrome of inappropriate secretion of antidiuretic hormone Superior vena cava syndrome Pulmonary thromboembolism Massive hemorrhage (i.e., hematemesis, hematochezia, and hemoptysis) Spinal cord compression Intracranial hypertension. To be able to describe the current status of cancer treatment in Japan. Course 22. Education and research GIO: To be able to contribute to the development of palliative care by being involved in education and research as well as constantly updating knowledge as a palliative care specialist. SBOs:
To be able to constantly strive to acquire the latest information related to doubts that arise daily at clinical sites To be able to learn basic educational techniques and implement them To be able to perform training, awareness-raising, and promotional activities for palliative care in one's facility and the surrounding region To become aware of the importance of clinical research and be able to participate in such research related to unsolved issues in palliative care To be able to critically appraise medical articles To be able to actively participate in academic meetings and workshops on palliative care and deliver presentations on medical care and clinical research results.
