Neurology
End of Life Content
Case Discussion – 70 year old patient with dementia
Questions: How do family or caregivers manage a bed bound demented patient? How would you treat aggressive behavior or hallucination? The inability of the patient to eat or drink on his own? Directives for EOL care (eg cardiopulmonary resuscitation)?
Case Discussion – 31 year old patient with progressive neuromuscular disease
Questions: Which neuromuscular disease has no curative treatment, progressing to dysphagia and respiratory failure? What do you discuss with the patient and family regarding feeding tubes, mechanical ventilation and cardiopulmonary resuscitation?
“Informally students may encounter neurology patients on ward service, or consult patients, who have terminal or untreatable disease or progressive neurological disease. The issues of appropriateness of care, surrogate decision making, use of aggressive medical management or not, means of nutrition or need for assisted ventilation are typically brought up in the daily team rounds or morning report”
Assessment
Written examination questions
End of Life Curriculum Goals and Objectives Assessed
Goal #1 Medical Knowledge
Students must demonstrate knowledge about the medical aspects of death and dying, as well as the skills and attitudes necessary to use this knowledge effectively as a physician.
- death is a natural part of the life cycle
- the pathophysiology and management of the common symptoms encountered at end of life:
- delirium
- dyspnea
- the potential adverse effects of common medications used for the control of symptoms of terminally ill patients
- the physiologic changes that occur as patients are dying
Goal #2 Communication Skills
Students must demonstrate knowledge of the principles of communication and the skills and attitudes that allow effective interactions with patients, families, healthcare workers, and others who affect the well-being of patients at the end of life. Students will be able to:
- elicit, record, and present a whole patient assessment for a person with a life-threatening illness
- demonstrate appropriate skills and strategies for communication of goals of care with patients and their families (e.g. living will, DNR, donor programs)
- demonstrate an understanding of the impact of life-threatening illness on patients and their families
- demonstrate appropriate skills and strategies for communication during difficult situations, such as giving bad news
- demonstrate appropriate skills and strategies for developing advance directives with patients and their families
- effectively communicate with patients and families in the face of sudden illness
- demonstrate and understanding of how family, culture, and religious beliefs can influence healthcare decisions and outcomes at the end of life
Goal #3 Professionalism
Students must demonstrate a combination of knowledge, skills, attitudes, and behaviors necessary to function as a member of the health care team caring for the dying
- identify the major obligations of physicians to their patients at the end of life
- Advocate at all times the interest of patients over personal interests
Goal #4 Patient Care
Students must use their knowledge, skills, and attitudes to provide patient care at the end of life that is appropriate, effective and sensitive to the psychological, sociologic, cultural and spiritual aspects of death and dying.
- identify the multiple determinants of suffering: physical, psychological, social, cultural and spiritual
- develop and implement a care plan for patients when cure is no longer a rational goal and health services are most appropriately directed at comfort
- apply knowledge to effectively evaluate and manage the most common physical symptoms encountered at the end of life
- apply knowledge of the points of consensus and controversy to make reasonable judgements regarding the following ethical aspects of end of life care:
- withholding treatment
- withdrawing treatment
Goal #5 Practice Based and Lifelong Learning:
Students should demonstrate the knowledge, skills, and attitudes needed to be able to begin to evaluate their method of practice, use appropriate tools of evidence to analyze clinical practice, and understand concepts of quality in healthcare and quality improvement for patients and their families at the end of life.
- Search, evaluate, and critically review scientific evidence appropriate to the care of individual patients with chronic debilitating illness and at the end of life
Goal #6 Social and Community Context of Healthcare
Students must demonstrate the knowledge, skills, attitudes necessary to function within the larger healthcare system in which they will receive further training and identify resources available to provide high-quality care for their patients.
- under supervision, develop diagnostic and treatment strategies that are cost-effective, sensitive to limited resources, and do not compromise quality of care
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