Postgraduate Diploma in Palliative Medicine

The purpose is to provide doctors with an understanding of the principles and practice of modern palliative medicine. This qualification provides opportunities for continued personal and career development. The distance learning aspect of the programme allows access to training for doctors in their own place of work and facilitates access to palliative care for all communities of Southern Africa.

The qualification is to provide our country with learners in palliative medicine capable of improving the quality of life for clients with advanced illness and their families in all communities and places of care, as clinicians, teachers and health advocates.

Entry Requirements

The minimum entry requirement for this qualification is

• Bachelor of Arts in Health Care Studies, Level 7.

Or

• Advanced Diploma in Health Management, Level 7.

N/A

1. The doctor will be able to describe the principles of modern palliative medicine and its role within the health care system and the doctor`s own role in applying professional principles in the care of terminally ill clients and their families.

Specific Outcome 1

• To understand the principles of modern palliative care.

Specific Outcome 2

• To understand the role of palliative medicine within the health care system.

Specific outcome 3

• To understand the public policy debate around the care of terminally ill clients and to contribute towards the development of humane, ethical and equitable public health policy.

Specific outcome 4

• To identify and meet one`s own learning needs through a process of critical self-appraisal and reflective learning.

1. The doctor will be able to describe the pathophysiology of the disease process in advanced illness with particular reference to malignant diseases, HIV/AIDS and progressive neurological disorders.

Specific Outcome 1

To know the patterns of disease, markers of disease progression and the range of treatments available at each stage of the disease for:

• Malignant diseases.
• AIDS.
• Progressive neurological disorders eg motor neurone disease.

Specific Outcome 2

• To be able to critically assess and re-evaluate the clinical situation as the disease progresses.

Specific Outcome 3

• To be able to anticipate potential problems caused by the disease or by treatments.

Specific Outcome 4

• To know the disease processes as they affect children.

1. To identify and describe common symptoms experienced by clients receiving palliative care and to describe management of these symptoms.

Specific Outcome 1

• To be able to determine the cause of individual symptoms.

Specific Outcome 2

To be able to manage specific symptoms appropriately.

Specific Outcome 3

• To recognise the limits of attainable symptom control.

Specific Outcome 4

• To demonstrate an understanding of the role of complementary therapies.

Specific Outcome 5

• To demonstrate an understanding of the use of palliative surgery, radiotherapy, chemotherapy and hormonal manipulation.

Specific Outcome 6

• To demonstrate an understanding of symptom control in children.

1. To demonstrate a knowledge of the pharmacological principles of drugs used in the palliative care management of clients who are terminally ill.

Specific Outcome 1

• To know what drugs are commonly used for the control of symptoms, their administration, dose-range and common adverse effects?

Specific Outcome 2

• To know the indications for a syringe driver, how to set up a syringe driver and the compatibility and miscibility of drugs used in a syringe driver.

Specific Outcome 3

To know the effects of renal or liver failure on metabolism and elimination of drugs commonly used in palliative medicine.

Specific Outcome 4

To be skilled in the use of opioids for pain control and to know the equivalent doses of different opioids.

Specific Outcome 5

• To be skilled in prescribing for children.

1. To demonstrate competence in interpersonal communication skills so as to effectively support client, family and carers in the face of advancing illness, death and bereavement.

Specific Outcome 1

• To assess the differing perceptions and expectations of disease and treatment amongst the various family members and to understand the psychodynamics of interpersonal relationships and the changes that can occur in illness.

Specific Outcome 2

• To demonstrate effective communication skills in the professional relationship with client and family.

Specific Outcome 3

• To understand grief and loss, facilitate the grieving process in adults and children by utilising personal, team and community resources.

Specific Outcome 4

• To recognise the sources and effects of one`s own opinions, feelings and judgements and to respond appropriately.

1. To recognise spiritual and cultural dimensions in the provision of culturally sensitive care based on respect for the uniqueness of the individual and on sound ethical principles.

Specific Outcome 1

• To recognise the importance of spiritual beliefs (or lack of beliefs) on the process of care.

Specific Outcome 2

• To deliver culturally sensitive care to the client and family in the face of terminal illness.

Specific Outcome 3

• To demonstrate a knowledge of sound ethical principles and an approach to ethical dilemmas facing the health care professional in palliative care.

1. To demonstrate effective interpersonal skills to facilitate working within an interdisciplinary team.

Specific Outcome 1

• To demonstrate an ability to work in a multi-disciplinary team.

Specific Outcome 2

• To understand the importance of communication and collaboration between health care professionals and health care agencies.

Specific Outcome 3

• To be able to provide practical support for the client receiving palliative care.

1. To be able to apply critical analysis and problem solving techniques in the investigation of palliative care problems through research that will contribute to the body of evidence-based medicine.

Specific Outcome 1

• To critically review, analyse and apply the results of health related literature to the doctor`s own investigation.

Specific Outcome 2

• To conduct his/her own research, the results of which will contribute to evidence-based medicine.

Specific Outcome 3

• To logically and critically develop, analyse and draw conclusions from the findings of the research.

Specific Outcome 4

• To communicate the results of the research in an acceptable manner which will enhance the transfer of knowledge.

Associated Assessment Criteria for Exit Level Outcome 1

1.1

• The doctor will be able to demonstrate a knowledge of the modern hospice movement.
• The doctor will be able to demonstrate a knowledge of the philosophy of palliative care and the World Health Organisation (WHO) definition of palliative care.
• The doctor will be able to demonstrate an awareness of international developments in palliative medicine.

1.2 The doctor will be able to describe the role of palliative care within the health care system with regard to systems of care, places of care, models of care, standards of care, collaboration between health care organisations.

1.3 The doctor will be able to demonstrate knowledge of current health policies and current legislation regarding health care and the constitutional rights of the individual.

• The doctor will be able to demonstrate an understanding of bio-ethical principles and an awareness of ethical dilemmas in palliative care and the role of the doctor as client/family advocate.
• The doctor will be able to demonstrate an awareness of the economic impact of changing health care policies.

1.4

• The doctor will be able to critically analyse the literature concerning the principles of palliative medicine.
• The doctor will be able to support clinical decisions with objective evidence.
• The doctor will be able to demonstrate skills in the diagnostic and therapeutic principles and practice of clinical palliative medicine.

Associated Assessment Criteria for Exit Level Outcome 2

2.1 The doctor will be able to describe the causes, pathophysiology, diagnosis and medical management of malignant diseases, Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome (HIV/AIDS and MND).

2.2 The doctor will be able to describe the progression of the illness and the appropriate interventions as the disease progresses.

2.3 The doctor will be able to describe the anticipated complications that may develop as the disease progresses and the potential side effects of treatment and the appropriate interventions.

2.4 The doctor will be able to describe the causes, pathophysiology, diagnosis and medical management of malignant diseases and HIV/AIDS in paediatric palliative care.

3.1 The doctor will be able to describe the causes of individual symptoms which may be

• Caused by the cancer or terminal illness itself.
• Caused by anti-cancer or other treatment related to the cancer and/or debility.
• Caused by a concurrent disorder.

3.2 The doctor will be able to describe the causes and management of symptoms in palliative care. The specific symptoms to be considered are:

• Pain-diagnosis of different types of pain: the differentiation between nociceptive and neurogenic pain.
• Pain assessment.
• Non drug treatment.
• The WHO 3 step ladder for pain management.
• The use of opioid analgesics.
• Responsiveness and resistance to opioids.
• The range of treatments for difficult pain problems.
• Gastro-intestinal symptoms:

> Anorexia.

> Nausea and vomiting.

> Constipation.

> Diarrhoea.

> Intestinal obstruction.

> Hiccups.

> Dysphagia.

> Oral symptoms.

> Sore mouth.

> Candidiasis.

> Respiratory symptoms.

> Cough.

> Dyspnoea.

- Neurological symptoms

> Depression and appropriate sadness.

> Fears and anxieties.

> Acute confusional states.

> Delirium.

> Dementias esp AIDS.

> Dementia.

> Dermatological conditions.

> Pressure care.

> Wound care.

> Skin conditions associated with HIV/AIDS.

> Stoma care.

> Lymphoedema.

> Genito-urinary symptoms.

> Incontinence.

> Bladder spasm.

> Urinary retention.

> Sexual problems.

> Infections in immuno-compromised clients, especially HIV infected patients.

> Post-chemotherapy.

> Management of common emergencies in palliative care.

> Hypercalcaemia.

> Spinal cord compression.

> Superior vena cava obstruction.

> Massive haemorrhage.

> Management of other distressing symptoms.

> Fungating lesions including malodour and choice of dressings.

> Fstulae.

> Restlessness in the last days of life.

> Raised intracranial pressure.

> Malignant effusions.

3.3 The doctor will be able to recognise the limitations in achieving symptom control and will be able to support the health care team, client and family in accepting these limitations.

3.4

• The doctor will be able to demonstrate a knowledge of the role of complementary therapies which may benefit the palliative care clientclient.
• The doctor will be able to demonstrate a critical awareness of therapies that may not be beneficial to the client.

3.5 The doctor will be able to demonstrate an understanding of the role of chemotherapy, radiotherapy, surgery and hormonal treatment in the active palliation of symptoms in the terminally ill client.

3.6 The doctor will be able to demonstrate a knowledge of palliation of symptoms in paediatric clients.

4.1

The doctor will be able to demonstrate a knowledge of the drugs used in palliative care, the indications for their use and the details of their prescription and administration.

• The doctor will be able to describe the common side effects of medications and will be able to explain the use of medications to client and family to enhance compliance.

4.2

• The doctor will be able to demonstrate a knowledge of the appropriate use of the syringe driver for delivery of drugs required in the terminal stages of illness.
• The doctor will be able to demonstrate a knowledge of the drugs that can be used subcutaneously by syringe driver, their compatibility and miscibility.

4.3

• The doctor will be able to demonstrate knowledge of the effect of renal and liver failure as disease progresses on drug metabolism and elimination and the necessary adjustments in medication.
• The doctor will be able to demonstrate an awareness of the need to review drug regimes as the clientclients condition changes.

4.4

• The doctor will be able to demonstrate a knowledge of the use of opioids for pain control.
• The doctor will be able to explain the WHO 3-step analgesic ladder.
• The doctor will be able to address concerns regarding the use of opioids and explain the use of opioids to clients and families to enhance compliance and optimal pain control.

4.5 The doctor will be able to demonstrate a knowledge of the appropriate use and prescribing of medication for children in palliative care.

5.1

• The doctor will be able to draw up a family tree (genogram) and understand its uses.
• The doctor will be able to facilitate family meetings to optimise client care.
• The doctor will be able to demonstrate an understanding of the different psychological responses in both client and family including anger, guilt, denial, acceptance, transference, collusion and conspiracy of silence, response to loss, hope.
• The doctor will be able to demonstrate an understanding of the responses of a child to illness and the effect of protracted childhood illness or a terminally ill child on a family.
• The doctor will be able to describe the client`s perception of his/her sexuality and body image and will be able to demonstrate an understanding of how alterations in libido affect a client`s health and relationship.
• The doctor will be able to demonstrate a sensitivity to the client`s need for privacy in order to express affection towards a partner and family members.

5.2

• The doctor will be able to demonstrate effective communication in establishing trust in a caring relationship by active listening and use of empathy.
• The doctor will demonstrate an ability to empower the client to exercise autonomy.
• The doctor will be able to demonstrate sensitivity in assessing the client`s level of awareness of illness, imparting appropriate information gently, breaking bad news, dealing with difficult questions, eliciting and dealing with fears.

5.3

• The doctor will be able to describe the perception of death in society and different cultures.
• The doctor will be able to describe an understanding of the normal process of grief and recognition of the client`s response to loss.
• The doctor will be able to help prepare the carers for bereavement and support the client in grief.
• the doctor will be able to anticipate and identify the complicated grief reaction and support and manage the client with a complicated grief reaction.
• The doctor will be able to assess the need for support of the other agencies.
• The doctor will be able to understand the impact of a childhood death on a family.
• The doctor will be able to demonstrate an understanding of bereavement in children and adolescents.

5.4

• The doctor will be able to recognise and deal with emotional stress in his/herself and others in the health care team.
• The doctor will be able to demonstrate insight into his/her own personal and professional limitations.
• The doctor will be able to describe his/her own opinions, feelings and judgements and to recognise the danger of transposing these onto clients and families.

6.1

• The doctor will be able to demonstrate an awareness of the impact of the beliefs of the client, the carers and the doctor on any process of care.
• The doctor will be able to demonstrate an awareness of the practices of the major religions as related to death.
• The doctor will be able to help meet a client`s spiritual needs either personally or by referral.

6.2

• The doctor will be able to demonstrate an understanding of and respect for the client`s cultural background.
• The doctor will be able to recognise the importance of cultural aspects on the client`s experience of illness, on the client`s and family`s experience and expectations of health care and on the client`s participation in decisions regarding health care.
• The doctor will be able to facilitate rituals and practices that are important to the client and family.
• The doctor will be able to work with interpreters who are trained and prepared for interaction with clients who are terminally ill.

6.3

• The doctor will be able to describe the ethical principles of autonomy, beneficence, non-maleficence and justice.
• The doctor will be able to demonstrate in practice respect for the client as a client (autonomy) which involves:

> Agreeing priorities and goals with the client and carers

> Discussing treatment options with the client and jointly formulating care plans

> Not withholding information desired by the client at the request of a third party

> Fulfilling the client`s need for information about any treatments

> Respecting the client`s wish to decline treatment.

> The doctor will be able to demonstrate an understanding or the concepts of respect for life and acceptance of death as a natural process.

> The doctor will be able to assess the risks vs benefits of each clinical decision.

> The doctor will be able to demonstrate an understanding of the issues which surround requests for euthanasia and an ability to discuss such a request in a sensitive and caring manner.

> The doctor will be able to describe an understanding of the right of the individual client to the highest standard of care within the resources available.

> The doctor will be able to demonstrate an understanding of the decisions involved in the allocation and use of resources in the provision of client care.

7.1

• The doctor will be able to demonstrate an awareness of skills in other members of the multi-disciplinary team and an understanding and respect for the role of each team member.
• The doctor will be able to demonstrate an awareness that effective leadership of the team may on occasions be best devolved on others.
• The doctor will be able to demonstrate an understanding of the value of team support mechanisms.
• The doctor will be able to demonstrate a sensitivity to the difficulties involved in teamwork.

7.2

• The doctor will be able to demonstrate an understanding of the relationship and responsibilities of the specialist towards the client and appropriate referral and feedback.
• The doctor will be able to demonstrate an understanding of the relationship between the client care team and the hospital based team.
• The doctor will be able to demonstrate an understanding of the importance of effective communication between health care professionals and the need for the client and family to understand the different roles of health care professionals.
• The doctor will be able to describe the local facilities for palliative care and to evaluate these facilities.
• The doctor will be able to promote and facilitate collaboration between public health services and NGOs involved in home-based care and in-client palliative care.

7.3

- The doctor will be able to describe how to obtain

> Practical appliances.

> Hospice home care services.

> Services of paramedical services.

> Physiotherapy, occupational therapy.

> Stomatherapy.

> Volunteer services to support the dying client/client at home.

> Relevant grants, funds and allowances.

8.1

• The doctor will be able to demonstrate knowledge of the relevant field of investigation.
• The doctor will be able to analyse and apply results of palliative care literature to his/her own field of investigation.

8.2

• The doctor will be able to select an appropriate topic for research.
• The doctor will be able to select the appropriate research paradigm (qualitative or quantitative) and method for investigation.
• The doctor will be able to apply the scientific method and tools correctly in the research process to solve a problem related to palliative care.

8.3

• The doctor will be able to analyse the data logically.
• The doctor will be able to review the findings in relation to existing knowledge and critically draw conclusions.

8.4

• The doctor will be able to apply relevant skills to communicate the results in written and oral form that will enable utilisation of the research by the profession.

Integrated Assessment

Integrated assessment is designed to collect evidence from the learner to demonstrate that the purpose(s) of the programme as a whole has been achieved, that the exit level outcomes have been attained. It is often used to assess, at the exit point from a programme, the integration and application of knowledge, skills (and values/attitudes) learnt from across all the component courses in a programme.

Inevitably, integrated assessment demands a variety of assessment methods such as portfolios, simulations, work-place assessment, written examinations, oral examinations. The combination of these methods provides evidence that the learner has achieved the applied competence at the exit point of a programme that the programme claims as its purpose. Learners on the programme will have the opportunity to be assessed through a range of methods for both formative and summative purposes.

The programme for the PGDip requires the completion of 10 written assignments, a portfolio project, a written examination, a communication skills assessment and an oral examination. The assessment for most of the modules will centre largely around practice-based projects, that is, within the boundaries of the course topic, learners will be able to identify problems or areas of interest which they want to explore further.

Learners will have the opportunity to display a range of foundational, practical and reflexive competencies developed through their experience as professionals and through the course.

Learners will describe a client history from their current medical practice to illustrate their understanding of palliative care or bereavement and the evolution of their knowledge and skills in palliative medicine. This commentary will be presented as part of a personal learning portfolio. Descriptions of sequential clinical contacts with clients and families will illustrate the depth of the personal learning process. Recently read reference material, quotations, diagrams, photographs, artwork and music can also be used. The final portfolio should reveal an evolution of thought and expression as well as knowledge and skills and should be of permanent value to the learners as a reference source.

During the course of the study weekends, there will be an opportunity for facilitator observation of the learners and interaction with the learners to enable the tutors to complete an assessment of the learners.

This programme has been developed in collaboration with the Section of Palliative Medicine in the department of General practice of the University of Wales College of Medicine. International palliative medicine physicians will act as external examiners in the initial programme.