EXCELLENCE IN END-OF-LIFE CARE: A COMPREHENSIVE REVIEW FOR PHYSICIANS

CME Series on End-of-Life Care by Project GRACE (Guidelines for Resuscitation and Care at End-of-Life); accredited and distributed by MECOP (Medical Educational Council of Pensacola)

COURSE DESCRIPTION

This course is intended to provide physicians and other health professionals with both primary and reference information on the current status and future needs for improvement of end-of-life care in the United States and is applicable to all peoples. Because of the length and comprehensive nature of this series and the variable knowledge and needs of intended participants, this document has been divided into separate CME offerings in 5 specific areas of end-of-life care:

(1) medical futility and the ethics of end-of-life care (1 hour);
(2) legal issues, including landmark legal cases and Advance Care Planning (1 hour);
(3) special clinical situations, including dementia, persistent vegetative state, CPR, and feeding tubes (½ hour);
(4) treatment options at end-of-life, including Hospice care, terminal analgesia and sedation, general principles of pain management, religious and cultural support, and the physician’s role in EOL care (1½ hour);
(5) case examples in end-of-life care (1 hour).

This CME activity is in a word text format followed by questions relative to that segment’s content including the introduction. Links are provided for resource material and additional pertinent information/knowledge. Click on the figures and tables in the text and on the web-based references in the end-notes for access.  If figures or tables are difficult to read on line, printing the figures for ease of study is recommended.  

Use the sidebar on the right to move to any part of the document by clicking on the name of the section. The Part numbers on the bottom will take you to the selected section of the CME activity. Participants are encouraged to access one or all five sections in this series to meet individual needs.

HARDWARE/SOFTWARE REQUIREMENTS

For this CME program, your computer should be Windows XP, Windows 98, Windows NT or Windows 2000 compatible. If you are using a modem to connect to the internet, you will need a modem speed of at least 56k.

PRIVACY POLICY

When you provide your personal information to MECOP (such as name, address, phone number, company name, email address, or credit card number,) we will not give or sell your individual information to any outside company for its use in marketing or solicitation. We will maintain the confidentiality of your personal information and it will be used only to support your customer relationship with MECOP.

ABOUT THE AUTHORS

Grounded in decades of contribution to the literature on end-of-life care by Dr. Lofty Basta, former Chairman of Cardiology at University of South Florida, and the tremendous clinical and teaching experience of Dr. Henry McIntosh, former President of the American College of Cardiology, Project GRACE originated as a unique lay-professional organization through the Florida Chapter, American College of Cardiology in 1999. Now an independent, non-profit organization, the mission of Project GRACE is to:

• Empower individuals to communicate and implement their specific end-of-life medical treatment decisions.
• Promote the belief that all persons are entitled to humane and dignified end-of-life care in keeping with their personal wishes, values and spiritual beliefs.
• Educate professionals and the community about effective advance care planning to ensure that end-of-life healthcare choices are honored.

The key to improving end-of-life care is the communication of clear and specific medical treatment decisions. To this end, Project GRACE has developed an Advance Care Plan document, which has been adopted and distributed by numerous major hospital systems and Hospices and health care organizations in Florida and throughout the United States. In addition, Project GRACE has supported legislation and professional and public educational activities that promote improved end-of-life care. The Board of Directors of Project GRACE includes physicians, nurses, attorneys, clergy, hospice leaders, and health care professionals as well as community leaders.

The following individuals, most of whom serve on the Project GRACE Board of Directors, have contributed significantly to this document: Rev. Celillon Alteme, Supervisor for Clinical Pastoral Education, Tampa General Hospital; Lofty L. Basta, MD, FACC, FRCP, FRCPE, FCCP, FACA, FAHA, founder Project GRACE & author, Life and Death on Your Own Terms; Erin Bowers, RN, BSN, MPA, NCBF, Palliative Care Coordinator, Sacred Heart Hospital; W. Daniel Doty (Editor), MD, FACC, FAHA , Chairman, Quality of Patient Care Committee, Florida Chapter, American College of Cardiology; Michael Geldart, JD, General Council, Chronic Care Solutions, Inc.; Juan C. Iregui, MD, Medical Director of Palliative Care, Sacred Heart Hospital; Sloan Beth Karver, MD, Chief of Palliative Care Service and Assistant Professor, Psychosocial and Palliative Care Program, Moffitt Cancer Center and President and Chairman of the Board, Project GRACE; Mary J. Labyak, MSSW, LCSW, President & CEO, The Hospice of the Florida Suncoast; Cynthia Paganini, MD, Education Committee Chair, Project GRACE; and Adelaida L. Torres, MD, Internal Medicine; Robert M. Walker, MD, Division of Medical Ethics and Humanities, University of South Florida.

DISCLOSURES

It is the policy of the Medical Educational Council of Pensacola that CME providers disclose pertinent relationships to supporting commercial entities or commercial entities that manufacture products/devices that may be mentioned during CME articles or presentations. The authors of this CME have no relevant relationships to disclose.

Date of original release December 2006
Course Expiration: CME credit is no longer available for this homestudy version after December 30, 2009.
Patent Pending

The Medical Educational Council of Pensacola gratefully acknowledges the assistance of:  

Preparation/Internet Publication by: Robin Key, MECOP Program Administrator

Collaboration by: MECOP Curriculum Committee: Dan Doty, MD; Adelaida Torres, MD; Robert Wilson, Jr.; MD, Raul Ramos, MD; Nina Clark, RN; Donna Jacobi, MD
Reviewed by: Raul Ramos, MD, Robert Wilson, Jr., Katherine Price, MD, Wendy Lockwood, MD, Lisa J. Weber, Barry Arnold, PhD, Karen Kendall, MSM, PT.

MECOP gratefully acknowledges the work, insight and effort from the creators of this CME activity through Project GRACE.

TARGETED AUDIENCE

Physicians and other providers of care at end-of-life.

DESIGNATION
 

This activity has been planned and implemented in accordance with the Essential Areas and Policies of the Accreditation Council for Continuing Education (ACCME).  MECOP is accredited by the ACCME to provide continuing medical education (CME) for physicians and takes responsibility for the content, quality, and scientific integrity of this CME activity.

The Medical Educational Council of Pensacola designates this educational activity for a maximum of 5 AMA PRA Category 1 Credits^TM. Physicians should only claim credit commensurate with the extent of their participation in the activity.
 

This program has been reviewed and is acceptable by the Florida Board of Nursing Home Administrators. 5 CEU.

This program has been reviewed and is acceptable by the Florida Board of Pharmacy. 5 CEU.

This program has been reviewed and is acceptable by the Florida Physical Therapy Association (FPTA). 6 CEU.

This program has been reviewed and is acceptable for 5 contact hours for Occupational Therapists & Occupational Therapist Assistants.

COURSE COMPLETION

Successful Completion: After concluding each course, complete the post-test, provide your identifying information, complete the evaluation and submit. Participant information must be completed, including License #. Sections may be submitted for CME individually or together through the Internet, by fax, or by mail. A minimum score of 80% must be achieved on post CME examinations to receive credit. If grade is less than 80%, MECOP will notify you of your score by telephone or e-mail and allow you to retake the test. You will not be charged until you successfully complete the test.

Method of Payment: Payment may be made by check, Master Card, Visa or American Express based on the following fees: Part 1 = $15, Part 2 = $15, Part 3 = $10, Part 4 = $20, Part 5 = $15. Fees will be discounted to a maximum of $50 total for all parts submitted within 60 days.

Test Completion Date: Your post-test completion date is determined by postmark date, facsimile date or online submission date only.

Turn Around Time: MECOP will grade your post-test within 2-3 weekdays. Your certificate of completion will be sent upon receipt of check or credit card number.

COURSE OBJECTIVES (includes the entire series)

1. To change dealing with death and dying from the most difficult and dreaded to one of the most important and rewarding aspects of practicing medicine, ultimately through providing our patients with a “good death.”

2. To understand the central role of proper advance care planning in empowering individuals to communicate and implement their personal wishes for end-of-life care.

3. To recognize the shortcomings of frequently used, vague, non-specific advance care plan documents and promote the widespread use of more effective, scenario-specific Advance Care Plans.

4. To supply the knowledge needed by physicians, nurses, attorneys, clergy, and others who counsel patients and families in order to communicate and implement a compassionate, holistic, rational approach to end-of-life care.

5. To appreciate the barriers to communication regarding end-of-life issues, including cultural, racial and spiritual differences in approach to decisions, and to strive to promote the choice of treatment options that allow patients to die with dignity, in accordance with their unique ethical, cultural and spiritual beliefs and values.

6. To understand the broad indications for using Hospice, hospital palliative care teams, bioethics committees and other grossly underutilized resources to provide a team approach to caring for dying patients.

7. To reassure healthcare providers that the total relief of pain, respiratory and emotional distress, and all other discomfort in dying patients through pharmacological and other interventions is humane and ethical, even if death is hastened.

8. To understand that the recognition of medical futility by both primary care and specialty physicians, which mandates a timely transition from futile curative treatment to palliative care and a good death, may be the greatest gift a physician can give to any patient.

9. To promote support for needed legislation and health care policies that encourage the completion of clearly written and understood advance care planning by all competent adults and the appropriate implementation of such planning through specific, end-of-life care orders (such as the Physician Order for Life Sustaining Treatment, or POLST form).

10. To become aware that physicians are legally bound to follow a patient’s Advance Directives and that medical liability lies not in failing to deliver futile care, but rather in contributing to a patient’s “bad death” through failure to honor the patient’s end-of-life decisions and right to die with dignity.

We invite you to share this valuable educational resource with your colleagues.

Introduction