Doctor of Medicine (MD) Palliative Medicine: Admission, Fees, Medical Colleges, Eligibility Criteria details

SECTION CD1: INTRODUCTION TO PALLIATIVE MEDICINE

Sl. No

Topic

Essentials

CD1.1 HISTORY OF PALLIATIVE MEDICINE

1.1.1

History of Palliative Medicine

• Ancient history of hospice care
• Dame Dr. Cicely Saunders and St. Christopher's Hospice
• History and philosophy of Hospice movement
• Modern Hospice movement and evolution of palliative care
• Evolution of Palliative Medicine
• History of Indian Palliative Care movement

CD1.2 PRINCIPLES OF PALLIATIVE MEDICINE

1.2.1

Principles of Palliative Medicine 1

• Definitions (Palliative Care, Palliative Approach, Palliative Procedure, Generalist and Specialist Palliative Care)
• Illness trajectories and stages
• Estimating the Palliative Care need
• Cardinal concepts underlying the philosophy of palliative medicine
• WHO Principles of Palliative Care
• Holistic Care

1.2.2

Principles of Palliative Medicine 2

• Principle 1: Unit of care includes patient and his/her family
• Principle 2: Symptoms must be routinely assessed and managed
• Principle 3: Decisions Regarding Medical Treatments Must Be Made in an Ethical Manner
• Principle 4: Palliative Care Is Provided through an Interdisciplinary Team
• Principle 5: Palliative Care Coordinates and Provides for Continuity of Care
• Principle 6: Dying Is a Normal Part of Life, and Quality of Life Is a Central Clinical Goal
• Principle 7: Palliative Care Attends to Spiritual Aspects of Patient and Family Distress and Well-being
• Principle 8: Palliative Care neither Hastens Death nor Prolongs Dying
• Principle 9: Palliative Care Extends Bereavement Support to Patients' Families
• Principle 10: Palliative Care Preserves and Enhances the Well-being of Clinical and Support Staff and Volunteers
• Principle 11: Palliative Care Engages in Continuous Quality Improvement and

Research Efforts

• Principle 12: Palliative Care Advocates for Patients and Families and Advances Public Policy to Improve Access to Needed Services and Quality of Care

CD1.3 SPECIALITY OF PALLIATIVE MEDICINE

1.3.1

Specialty of Palliative Medicine

• Levels of Care (Level 1-3)
• Development of Palliative Medicine Specialty
• Core competencies of a Palliative Medicine Physician
• Specialist Palliative Medicine Service
• CanMEDS Physician Competency Framework
• How to avoid downsides involved in specialist training

CD1.4 MULTIDISCIPLINARY TEAM

1.4.1

Multidisciplinary team 1

• Concept of Shared Care
• Multidisciplinary and Interdisciplinary team
• Role of a nurse in palliative care
• Role of a medical social worker in palliative care
• Role of occupational and physiotherapist in palliative care
• Role of Clinical Psychologist/Counselor in palliative care
• Role of nutritionist in palliative care

1.4.2

Multidisciplinary team 2

• Role of wound and stoma therapist in palliative care
• Role of speech and language specialist
• Role of volunteer in palliative care
• Role of chaplain and spiritual care person in palliative care
• Role of clinical pharmacist in palliative care
• Role of music therapist/art therapist/play therapist
• Role of yoga and complimentary and alternative medicine specialist

CD1.5 MODELS OF PALLIATIVE CARE DELIVERY

1.5.1

Models of Palliative Care Delivery 1

• Stjernswärd's Palliative Care for all Model
• Early Palliative Care
• Acute Palliative Care

• Integrated model
• Simultaneous and shared care model

(Description of model, mode of service delivery, advantages and disadvantages, evidence in literature)

1.5.2

Models of Palliative Care Delivery 2

• In-patient palliative care unit
• Hospice (Free standing unit)
• Hospital palliative care team (consultation liaison service)
• Community palliative care service (Home based palliative care)
• Out-patient palliative care unit
• Day palliative care unit

(Team composition, scope of service, skills, staffing, infrastructure, benefits and disadvantages)

CD1.6 RESEARCH IN PALLIATIVE MEDICINE

1.6.1

Research in Palliative Medicine 1

• Scope of research in Palliative Medicine
• Ethics of research in Palliative Medicine
• Barriers for research in Palliative Medicine
• Evidence based Palliative Medicine

(Oxford CEBM levels of evidence, Obtaining evidence, Developing a citation database for review, Judging the quality of trials, Judging the quality of review, Critical evaluation of a RCT and systematic review)

• Conducting a clinical trial in Palliative Medicine

1.6.2

Research in Palliative Medicine 2

• Writing a research protocol in Palliative Medicine

(Identifying the research area, defining the clinical problem, literature review, formulating the research question, defining objectives and patient population, appropriate study design, methodology, outcomes to be measured, statistical consideration, interpretation of results and arriving at conclusion)

• Qualitative research in Palliative Medicine
• Psycho-social research in Palliative Medicine

CD1. scales and tools

1.7.1

Scales and tools 1

• Broad multi-symptom assessment scales and

tools

• Performance status scales and tools
• Pain assessment scales and tools
• scales and tools used to measure dyspnea
• scales and tools used to measure fatigue
• scales and tools measuring delirium
• scales and tools used for assessment of anxiety
• scales and tools used for measuring depression

1.7.2

scales and tools 2

• scales and tools measuring distress
• scales and tools measuring spiritual and existential distress
• scales and tools measuring coping and adaptation
• Scales and tools measuring social issues
• Scales and tools measuring care-giving issues
• Scales and tools measuring family issues
• Scales and tools measuring communication and satisfaction with care
• Scales and tools measuring sexuality and intimacy
• Scales and tools measuring pediatric aspects of advanced illness

CD1.8 ADVOCACY IN PALLIATIVE MEDICINE

1.8.1

Advocacy

• Policy Advocacy (Advocating for institutional, state/national palliative care policy)
• Capacity Building Advocacy (Advocacy for resources/funds to develop infrastructure needed for palliative care provision)
• Drug Availability Advocacy (Advocacy for improving access to pain and symptom control drugs – Essential Medication List)
• Education Related Advocacy

CD1.9 HEALTH POLICY AND PROGRAMS IN PALLIATIVE MEDICINE

1.9.1

Policy, Programs and Regulations

• Maharashtra and Kerala State Palliative Care Policy
• WHO Palliative Care Collaborating Centers and their activities
• Network neighborhood in Palliative Care
• National Palliative Care strategy for India

• Narcotic drugs and psychotropic substance (NDPS) act and its amendments

CD1.10 QUALITY AND STANDARDS IN PALLIATIVE MEDICINE

1.10.1

Quality and Standards

• Quality and Standards in Palliative Medicine
• Classification and Types of Standards
• Country specific International Standards for Palliative Care
• End of Life Care Standards
• The Gold Standards Framework
• Clinical Practice Guidelines as applicable to Palliative Care

SECTION CD2: PALLIATIVE PHARMACOLOGY

Sl. No

Topic

Essentials

CD2.1 PAIN PHARMACOLOGY

2.1.1

Non-steroidal anti- inflammatory drugs

• Cyclooxygenase (COX) pathway
• Classification (Classification based on COX, Efficacy, Potency)
• Pharmacokinetics
• Type A and Type B reactions
• NSAIDS and organ system (Renal, Hepatic, Cardiovascular, Gastrointestinal, Lung, Platelets, Bone, Genitourinary)
• Individual pharmacology of commonly used NSAIDs (Aspirin, Diclofenac, Paracetamol, Ibuprofen, Ketorolac, Oxicams, Etorocoxib)
• Rational NSAID prescription
• Safe NSAID prescription

2.1.2

Opioids 1

• Opioids definitions
• Opioid receptors
• Opioid classification (Chemical and Receptor based classification)
• Opioid metabolism and metabolites
• Pharmacokinetics
• Opioid use in renal and hepatic impairment
• Common adverse effects of opioids and its management
• Systemic effects of long term opioid use
• Opioids induced respiratory depression
• Opioids induced hyperalgesia

2.1.3

Opioids 2

• Opioid potency and conversion tables

• Opioid rotation
• Individual pharmacology of weak opioids (Codeine, Tramadol, Tapentadol, Dextropropoxyphene)
• Individual pharmacology of strong opioids (Morphine, Fentanyl, Buprenorphine, Oxycodone, Hydromorphone)
• Initiating a patient on strong opioids and titration of dose
• Using strong opioids - Instructions to patients and caregivers

2.1.4

Adjuvant Analgesics 1

(Adjuvants used in neuropathic pain)

• Anti-depressants (TCAs and SSRIs)
• Anti-epileptics
• Anti-arrhythmic (Na Channel Blockers)
• NMDA Receptor antagonists
• K Channel openers
• Drugs causing activation of GABA inhibitory and Glutamate excitatory system
• Corticosteroids
• Neuropathic Pain Step Ladder

2.1.5

Adjuvant Analgesics 2

• Adjuvant analgesics used in bone pain (Dexamethasone, Calcitonin, Bisphosphonates)
• Adjuvant analgesics used in GI pain (Hyoscine, Dicyclomine, Octreotide)
• Adjuvant analgesics used in genitourinary pain (Oxybutynin, Tolterodine, Solifenacin, Phenazopyridine, Propantheline, Tamsulosin, Flavoxate)
• Adjuvants in myofacial pain and muscle spasms (Baclofen, Flupirtine, Eperisone, Tolperisone, Thiocolchicoside)

CD 2.2 PHARMACOLOGICAL MANAGEMENT OF NAUSEA, VOMITING,

CONSTIPATION

2.2.1

Nausea and Vomiting 1

• Physiology of nausea and vomiting
• Emesis pathway
• Physiology of vomiting centers
• Receptors and neurotransmitters involved in Nausea and Vomiting
• Classification of anti-emetics (Central and GIT)
• Receptor sites and affinities of anti-emetics
• Classification of prokinetics based on

receptor action

• Pharmacological management of chemotherapy and radiotherapy induced nausea and vomiting.

2.2.2

Nausea and Vomiting 2

• Detailed pharmacology of individual drugs used in nausea and vomiting (Metoclopramide, Domperidone, 5HT3 antagonists)
• Anti-histaminic Anti-muscarinic drugs in nausea and vomiting
• Psychotropic drugs in nausea and vomiting
• Miscellaneous drugs in nausea and vomiting (Corticosteroids, Benzodiazepines, Cannabinoids, NK receptor antagonists)

2.2.3

Constipation

• Classification of aperients (Laxatives)
• Detailed pharmacology of commonly used drugs (Docusate, Bisacodyl, Lactulose, Macrogol, Senna, Magnesium compounds, Methyl Naltrexone)
• Rectal products (Suppositories, Micro and Standard Enema)
• Pharmacological management of opioid induced constipation,
• Pharmacological management of constipation in paraplegia/quadriplegia,
• Common drugs used in diarrhea.

CD2.3 CARDIOVASCULAR, RESPIRATORY AND CNS DRUGS IN

PALLIATIVE CARE

2.3.1

Cardiovascular

• Diuretics
• Optimizing and stopping cardiovascular drugs in palliative phase of illness trajectory
• Pharmacological management of cancer thrombosis, deep venous thrombosis and pulmonary embolism

2.3.2

Respiratory

• Oxygen and intermittent/long term oxygen therapy in palliative care
• Bronchodilators (oral/parenteral/inhaled)
• Drugs used in management of dyspnea
• Drugs used in management of cough
• Drugs used in management of respiratory secretions

2.3.3

CNS

(Anxiolytics, Anti- depressants and Anti- psychotics)

• Benzodiazepines in palliative care practice (classification, pharmacology of individual drugs, rational usage)
• Prescribing anti-depressants in palliative care practice (commonly used drugs and their pharmacology)
• Drugs used in delirium (typical and atypical anti psychotics)
• Drugs used in managing terminal restlessness (step ladder and pharmacology of drugs used in terminal sedation)

CD2.4 TOPICAL AGENTS USED IN PALLIATIVE MEDICINE

2.4.1

Topical Agents

• Topical agents used for dry mouth, excessive salivation, mucositis, apthous ulcers, oral candida
• Topical agents for managing dry skin, pruritus, pressure sores, non healing/foul smelling/bleeding wounds
• Topical anal preparations
• Topical eye preparations

CD2.5 DRUG INTERACTIONS IN PALLIATIVE MEDICINE

2.5.1

Drug Interactions

• Serotonin syndrome
• QT prolongation
• Drug induced movement disorders
• Synergistic sedation
• Metabolic interactions (Cytochrome P450)
• Pharmacokinetic interactions

CD2.6 PARENTERAL ANALGESIC PREPARATIONS

2.6.1

Parenteral analgesic infusions

• Preparing analgesic infusions (non opioids, weak opioids, strong opioids)
• Syringe driver preparations
• Syringe driver compatibility and interactions
• Managing a patient on syringe driver
• Drugs used in epidural and intrathecal analgesia

CD2.7 PRESCRIBING PALLIATIVE DRUGS IN SPECIAL SITUATIONS

2.7.1

Palliative drugs in special situations

• Palliative drugs in renal dysfunction
• Palliative drugs in hepatic dysfunction
• Palliative drugs in a patient with cardiovascular morbidity
• Palliative drugs in children
• Palliative drugs in elderly

• Palliative drugs in cognitive impairment

SECTION CD3: SYMPTOM CONTROL IN PALLIATIVE MEDICINE

Sl. No

Topic

Essentials

CD3.1 PAIN

3.1.1

Introduction to Pain

• Pain definition(s).
• Pain taxonomy.
• Pain classification(s).
• Acute/chronic/cancer pain-approach and differences
• Breakthrough pain
• Pain Crisis
• Emory pain estimate model.
• General principles involved in managing a patient with pain in a palliative care setting.

3.1.2

Mechanism of Pain 1

• Anatomy of pain pathway.
• Peripheral and spinal pain mechanisms: Nociception and anti-nociception.
• Nociceptors
• Transductionof nociceptive pain.
• Transmission of nociceptive pain.
• Modulation of nociceptive pain.
• Perception of nociceptive pain.

3.1.3

Mechanism of Pain 2

• Nerve injury
• Peripheral and central sensitization
• Modulation in neuropathic pain.
• Pathophysiological basis of hyperalgesia/allodynia.
• Structural anatomy of bone in relation to malignant bone pain.
• Pathophysiological mechanisms involved in malignant bone pain.

3.1.4

Assessment of Pain

• Medical evaluation of a patient with pain.
• Measurement of pain and pain assessment tools – both nociceptive and neuropathic. Role of investigations/imaging in pain patients.
• Total pain –psychological/psychosocial evaluation in pain.
• Evaluation of pain associated impact and disability.

3.1.5

Cancer Pain

• Cancer related acute pain situations

Syndromes

(Diagnostic/Therapeutic interventions, anti- cancer therapy, complications)

• Cancer related chronic pain situations (Direct tumor related, anti-cancer therapy, complications, Paraneoplastic)

3.1.6

Cancer Associated Nociceptive Pain

• Visceral pain syndromes
• Genitourinary pain syndromes
• Vascular pain syndromes
• Cancer related headache and facial pain,
• Paraneoplastic nociceptive pain syndromes
• Lymphedema associated pain
• Inflammation/infection associated pain

3.1.7

Malignant Bone Pain

• Bone pain syndromes
• Pain in vertebral and long bone metastasis
• Mirel's scoring system
• Imaging modalities in bone pain,
• Management of bone pain (Analgesic step ladder, Bisphosphonates, Calcitonin, Radiotherapy, Radioisotopes, closed and open surgical interventions, chemo/hormonal and targeted therapy)

3.1.8

Cancer Associated Neuropathic Pain

• Direct nerve injury (all plexopathies, painful mononeuropathy
• Paraneoplastic sensory neuropathy
• Malignant painful radiculopathy
• Painful cranial neuralgias),
• Cancer treatment associated nerve toxicity (chemotherapy/RT associated neuropathy)
• Surgical neuropathies (Phantom limb, post mastectomy/post thoracotomy syndromes)
• Current guidelines for neuropathic pain management.

CD3.2 GASTROINTESTINAL SYMPTOMS

3.2.1

Nausea and Vomiting

• Definitions and Epidemiology
• Etiological classification of Nausea and Vomiting in Palliative Care
• Approach to a patient with Nausea and Vomiting
• Opioid induced Nausea and Vomiting
• Chemotherapy induced Nausea and Vomiting
• Radiotherapy induced Nausea and Vomiting
• Etiology specific rational management of

nausea and vomiting.

3.2.2

Constipation and Diarrhea

• Comprehensive Definition/Classification
• Etiology of constipation in a palliative care setting
• Clinical approach and rectal examination
• Constipation assessment scales
• Principles of managing constipation and pharmacological approach
• Opioid induced constipation
• Managing constipation in a patient with paraplegia
• Assessment and management of diarrhea in palliative care practice

CD3.3 RESPIRATORY SYMPTOMS

3.3.1

Dyspnea

• Prevalence of dyspnea in life limiting conditions
• Pathophysiology of dyspnea
• Physiological classification of dyspnea in PC
• Assessment of dyspnea (Quality, Intensity, Impact, Distress)
• Four quadrant approach in management of dyspnea (Medical, Rehab, Palliative and End of Life Model)
• Palliative Pharmacology of Dyspnea
• Morphine in Dyspnea
• Oxygen in Dyspnea
• Non Pharmacological management of dyspnea
• Palliative Sedation in Intractable Dyspnea

3.3.2

Cough, Hemoptysis Respiratory Secretions, Bronchorrhea

• Cough (Pathway, Causes of cough in PC setting, Non-pharmacological management, Pharmacological treatment, Management of Refractory Cough)
• Hemoptysis (Classification – Minimal, Active, Massive, Pseudo)
• Hemoptysis (Causes in PC setting, Assessment, Non Pharmacological management, Pharmacological treatment, Interventions)
• Palliation of Massive Hemoptysis.
• Respiratory secretions (Prevalence, Classification, Presentation, Non Pharmacological management,

Pharmacological treatment).

• Bronchorrhea (Prevalence, Clinical features, Management)

CD3.4 CNS SYMPTOMS

3.4.1

Delirium

• Understanding consciousness (Awakeness, Awareness and Alertness)
• Neurophysiology of Delirium
• Epidemiology and risk factors
• Clinical features
• Tools used in Delirium Assessment
• Bedside assessment of Delirium
• Delirium types (Hypoactive/Hyperactive/Mixed)
• Differential Diagnosis
• Management of Delirium (Risk assessment, Prevention, Education, Safety, Non Pharmacological treatment, Pharmacological treatment)
• Terminal Delirium

CD3.5 MISCELLANEOUS SYMPTOMS

3.5.1

Miscellaneous symptoms 1 (Hiccoughs, Pruritus, Sweats, Dysphagia)

• Hiccoughs (Definition, Classification, Hiccoughs pathway, Etiology in palliative care setting, Non pharmacological and pharmacological management, treatment of refractory hiccoughs)
• Pruritus – (Classification based on duration, Etiology, clinical presentation) (Pruritus pathway, chemical mediators, causes and mechanism) (Overall management and classification of drugs used in pruritus) (Pharmacological and non pharmacological management each type)
• Sweats (Etiology, Assessment and Management)

3.5.2

Miscellaneous symptoms 2 (Fatigue and Edema)

• Etiology of fatigue in a PC setting
• Pathophysiological mechanisms of fatigue
• Clinical Assessment and Tools used in Fatigue Assessment
• Non pharmacological and pharmacological management of fatigue
• Edema in PC setting
• Assessment and Management of Edema (excluding Lymphedema)

SECTION CD4: PALLIATIVE MEDICINE IN AN ONCOLOGY SETTING

Sl. No

Topic

Essentials

CD4.1 BASICS OF ONCOLOGY

4.1.1

Cancer Epidemiology

• Cancer trends in India (Incidence and Mortality)
• Cancer etiology, risk factors and risk assessment (Tobacco, Infections, Diet, Life style, Physical and Chemical factors)
• Hereditary and Familial Cancer Syndromes

4.1.2

Cancer Biology and Natural History of Cancer

• Cancer Hallmarks (Tumor Biology, Cell cycle, Apoptosis, Cancer Stem cells, Proto- oncogenes, Tumor suppressor genes, Angiogenesis, Invasion and Metastasis)
• Cancer Genetics

4.1.3

Principles of Anticancer Therapy

• Classification, pharmacokinetics and pharmacodynamics of anticancer drugs
• Indications, dose/dose schedules, toxicity of commonly used anti-cancer drugs
• Principles, uses and pharmacology of drugs used in hormone therapy

4.1.4

Palliative Surgery

• Principles of palliative surgery in oncology setting
• Indications, morbidities of palliative surgery in individual cancer
• Common palliative surgery procedures (Colostomy, Ileostomy, Gastrostomy, Urinary diversion procedures, Tracheostomy, Stenting, ERCP/PTBD and other interventional surgical/radiological procedures)
• Orthopedic surgeries in palliative care.

4.1.5

Palliative Chemotherapy

• Principles of Cancer Chemotherapy and Palliative Chemotherapy
• Definition, Principles of Adjuvant and Neoadjuvant chemotherapy.
• Indications, principles and use of metronomic chemotherapy.

4.1.6

Palliative

Radiotherapy

• Principles of Palliative Radiotherapy
• Role of RT in brain and malignant spinal

cord compression

• Role of RT in skeletal metastasis
• Role of RT in visceral and soft tissue metastasis
• Role of RT in Hemostasis, Analgesia and management of Obstructive symptoms

CD4.2 PALLIATIVE MANAGEMENT OF COMMON CANCERS

4.2.1

Head and Neck, Brain and Thoracic cancers

• Stage-wise management of head and neck cancers
• Palliative RT and metronomic chemotherapy in Palliative/Advanced Head and Neck Cancers
• Management of low grade and high grade brain tumors
• Role of Palliative RT in patients with GBM with low KPS/Management of brain stem gliomas and recurrent brain tumors
• Palliative management of advanced esophageal cancers and palliative treatment of dysphagia
• Palliative management of advanced lung cancers

4.2.2

Breast and Genito- urinary cancers

• Stage-wise management of breast cancer
• Palliative management of advanced breast cancer
• Treatment algorithm of common genito- urinary cancers
• Palliative RT for advanced genito-urinary cancers
• Palliative chemotherapy for advanced genito- urinary cancers
• Palliation of obstructive Uropathy

4.2.3

GIT Cancers including Hepatobiliary

• Stage-wise management of GIT/Hepatobiliary cancers
• Palliative RT indications and schedules in advanced GI cancer
• Palliative chemotherapy for advanced GI/Hepatobiliary cancers
• Palliation of bleeding, obstructive jaundice, malignant ascites

4.2.4

Pediatric cancers, soft

tissue tumors,

• Treatment algorithms for common pediatric

cancers

leukemia and lymphoma

• Palliative chemotherapy regimens for advanced/relapse and recurrent pediatric solid tumors, lymphomas and leukemia
• Palliative RT indications and schedules In pediatric solid tumors and lymphomas

CD4.3 CANCER COMPLICATIONS AND ONCOLOGICAL EMERGENCIES

4.3.1

Neurological Complications and Emergencies 1

Malignant Spinal Cord Compression

• Anatomy of Spinal Cord
• Epidemiology, Types, Frequency
• Clinical presentation
• Investigations
• Conservative Management
• RT/Surgery and other interventions
• Prognostication
• Evidence base for each intervention

4.3.2

Neurological Complications and Emergencies 2

• Status Epilepticus
• Brain Metastasis
• Raised Intracranial Pressure (Cerebral Edema)
• Encephalopathy (Structural, Metabolic, Septic)

4.3.3

Hematological and Vascular Complications and Emergencies

• Malignant SVC Obstruction
• Deep venous thrombosis and Pulmonary Embolism
• Hemorrhage
• Tumor Lysis Syndrome
• Neutropenic sepsis

4.3.4

Gastrointestinal, Thoracic, Genitourinary, Bone and other Complications and Emergencies 1

Malignant Bowel Obstruction (MBO)

• Physiologic reactions to Malignant Bowel Obstruction
• Etiological of bowel obstruction in a patient with advanced cancer
• Approach to a patient with bowel obstruction
• Proximal versus Distal Bowel obstruction
• Rationally investigating a patient with MBO
• When to consider conservative management in MBO
• Principles and steps involved in conservative management of MBO
• Pharmacology of drugs used in MBO
• Interventional techniques in MBO
• Nutrition in MBO

• Prognostication in MBO

4.3.5

Gastrointestinal,

• Malignant Ascites

Thoracic,

• Malignant Pleural and Pericardial Effusion

Genitourinary, Bone

• Obstructive Uropathy

and other

• Pathological fractures

Complications and

• Airway obstruction and Stridor

Emergencies 2

• Managing Pain Crisis

• Managing Opioid Overdose

SECTION CD5: PALLIATIVE MEDICINE IN A NON ONCOLOGY SETTING

Sl. No

Topic

Essentials

CD5.1 END STAGE ORGAN FAILURE

5.1.1

End stage Chronic Lung Disease (CLD)

• Defining End Stage COPD
• Symptomatology of end stage COPD,
• Initiation of palliative medicine in end stage COPD (Gold Standards Framework)
• 4 quadrant approach (Medical, Rehab, Palliative and EOLC)
• Dyspnea management stepladder
• Medical and Rehab models
• Palliative Model (Pharmacological/Non pharmacological)
• Opioids in Dyspnea (Mechanism/dose/evidence)
• Guidelines for initiating EOLC model in end stage COPD
• EOLC in end stage COPD
• Palliative Sedation in refractory dyspnea.

5.1.2

End stage Congestive Heart Failure (CHF)

• Defining end stage cardiac failure
• Illness trajectory and various trajectory models
• Heart failure stages as relevant to palliative care
• Symptomatology of CHF
• Initiating palliative medicine in end stage CHF
• Triggers for palliative medicine referrals
• Guidelines for palliative medicine referral
• Palliative approach in end stage CHF
• EOLC in CHF

5.1.3

Chronic Kidney

• Defining CKD and ESRD

Disease (CKD) and End Stage Renal Disease (ESRD)

• Burden of ESRD
• Symptom burden of ESRD
• Management of pain in patients with ESRD
• Managing non-pain symptoms in ESRD,
• Non dialysis supportive care approach in CKD/ESRD
• Managing end of life in patients on dialysis
• Guidelines/recommendations for not initiation/withdrawal of dialysis.

5.1.4

End Stage Liver Disease (ESLD)

• Defining ESLD
• Symptom burden in ESLD and management of ESLD symptoms
• EOL transitions in ESLD (Child Pugh's / MELD scoring)
• Prognostication in ESLD
• Palliative and EOLC approach in ESLD

5.1.5

Palliative Neurology 1 (Symptoms and Impairment)

• Specific symptoms in advanced neurological illness (Muscular weakness, spasticity, dystonia, seizures, muscle cramps, involuntary movements, dyskinesia)
• Management of impairments secondary to advanced neurological illness (speech difficulty, dysphagia, drooling of saliva, breathing difficulty, urinary retention, bladder spasms, bowel and bladder incontinence, sexual dysfunction, autonomic dysfunction)

5.1.6

Palliative Neurology 2 (Motor Neuron Disease)

• Classification, Clinical Presentation
• Symptom prevalence in MND
• Etio-pathogenesis, impact and management of dysarthria
• Management of dysphagia and Sialorrhea
• Pain in MND (Etiopathogenesis and Management)
• Dyspnea in MND (Management, Non- invasive ventilation, weaning of respiratory support)
• Interdisciplinary care in MND
• End of Life Care in MND

5.1.7

Palliative Neurology 3

(Other neurological conditions needing

• Palliative Care in cerebrovascular disease
• Palliative Care in demyelinating disease
• Palliative Care in Parkinson's disease

Palliative Care)

• Palliative Care in Muscular dystrophy
• Palliative Care in Huntington's disease
• Palliative Care in traumatic and hypoxic brain injury
• Palliative care in congenital and acquired peripheral neuropathy

CD5.2PALLIATIVE MEDICINE IN HIV/AIDS

5.2.1

Palliative Medicine in HIV AIDS 1

• HIV infections and AIDS (Epidemiology, Biology, Natural History, Pathogenesis, Phases)
• Clinical Course of AIDS
• AIDS Defining Complex
• Anti-retroviral therapy
• Infections in an immunocompromised patient
• Non infective complications of HIV/AIDS

5.2.2

Palliative Medicine in HIV AIDS 2

• Symptom prevalence in HIV/AIDS
• Etiopathogenesis of pain in a patient with HIV/AIDS
• Etiopathogenesis of non pain symptoms in a patient with HIV/AIDS
• Management of pain and non pain symptoms in HIV/AIDS
• Palliative Care in HIV/AIDS (Principles and Approach, Advanced Care Planning, Stopping ART, Stopping infection prophylaxis)
• Addressing non physical issues in a patient with HIV/AIDS

CD5.3 PALLIATIVE MEDICINE IN DEMENTIA

5.3.1

Palliative Medicine in Dementia 1

• Epidemiology of Dementia
• Pathophysiology and classification
• Alzheimer's Disease
• Frontotemporal Dementia
• Lewy Body Dementia
• Dementia in Parkinson's disease,
• Dementia due to Huntington's disease,
• Vascular Dementia
• HIV associated Dementia

5.3.2

Palliative Medicine in Dementia 2

• Clinical features of Dementia
• Diagnostic criteria according to DSM-5 and ICD-10
• Psychiatric and neurological changes in

Dementia

• Course and prognosis
• Pharmacological and non pharmacological treatment
• Palliative and end of life care in dementia

CD 5.4 MISCELLANEOUS NON ONCOLOGICAL CONDITIONS

5.4.1

Palliative Medicine in Hematological Disorders

• Challenges and barriers in PC provision in incurable benign hematological disorders
• Palliative Care in Sickle Cell Disease (Inheritance, Clinical presentation, symptoms, needs, communication and long term management)
• Palliative Care in Thalassemia Major (Inheritance, Clinical presentation, symptoms, needs, communication and long term management)
• Palliative Care in other congenital hematological disorders (both anemia and bleeding diathesis)

5.4.2

Palliative Medicine in Immunological Disorders

• Palliative Care in advanced Vasculitis
• Palliative Care in malignant course of Rheumatoid Arthritis
• Palliative care in advanced stages of connective tissue disorders such as Systemic Lupus Erythematosus, Progressive Systemic Sclerosis, Mixed Connective Tissue Disorder, and Sjogren's syndrome etc.
• Palliative Care in Progressive Pulmonary Fibrosis

5.4.3

Palliative Medicine in congenital and post traumatic disability

• Technical definitions - Disability, Impairment, activity limitation, participation restriction
• Classification of disabilities
• Interphase of Rehabilitation and PC in a patient with disability
• Palliative care for a patient with traumatic paraplegia and quadriplegia
• Palliative care for a patients with traumatic brain injuries, persistent vegetative states
• Palliative Care in congenital disabilities

5.4.4

Palliative Medicine in

MDR and XDR

• Criteria for diagnosing MDR and XDR TB
• Clinical presentation, symptoms and

Tuberculosis

complications

• Pharmacological management of MDR and XDR TB
• Palliative Care and End of Life Care needs in MDR XDR TB
• Geneva Declaration of Palliative Care and MDR/XDR-TB

SECTION CD6: SUPPORTIVE CARE IN PALLIATIVE MEDICINE

Sl. No

Topic

Essentials

CD6.1 MANAGING COMMON COMPLICATIONS IN A PALLIATIVE MEDICINE

SETTING

6.1.1

Dehydration and Shock

• Approach to a patient with shock.
• Hypovolemic shock diagnosis and management.
• Differentiating types of shock.
• Types of resuscitation fluids, its constituents and rational use

6.1.2

Fever and Sepsis

• Various definitions used in the diagnosis of sepsis.
• Fever – Types of fever.
• Bacteremia, Septicemia, SIRS, Sepsis, Severe Sepsis, Septic Shock, Refractory Septic Shock, MODS.
• Approach to a patient with sepsis.
• Complications of sepsis
• Managing a patient with sepsis (investigations + treatment). Rational use of broad-spectrum antibiotics

6.1.3

Anemia and Transfusion

• Anemia in advanced illness: prevalence, significance, and causes.
• Approach to a patient with anemia of chronic disease and cancer.
• Approach and diagnostic modalities
• Role of iron supplements
• Role of erythropoiesis stimulating agents
• Blood and component transfusion
• Assessment of fatigue and symptom benefit post blood transfusion
• Decision making on withholding transfusion

6.1.4

Anorexia-Cachexia Syndrome (ACS)

• Definition and classification of ACS
• Etiology of ACS in a Palliative Care setting
• Pathogenesis of primary and secondary ACS
• Diagnosis, Clinical Presentation and stages
• Clinical assessment of ACS
• Pharmacological management of ACS
• Nutrition in ACS

6.1.5

Thrombotic disorders in Palliative Medicine

• Cancer associated thrombosis (pathophysiology + approach)
• Swollen legs in a palliative care setting (differentiating venous thromboembolism [VTE] from others),
• Recognition, confirmation and management of VTE.
• Guidelines on using anti-coagulants in VTE

– how long/how to monitor/when to discontinue.

• Special situations – SVC thrombosis, portal venous thrombosis, cavernous venous thrombosis.

CD6.2 MANAGING CONCURRENT ILLNESS IN A PALLIATIVE MEDICINE

SETTING

6.2.1

Electrolyte Imbalance 1

Hyponatremia, Hypernatremia

• Approach to a patient with hyponatremia.
• Hypovolemic hyponatremia
• Euvolemic hyponatremia
• Hypervolemic hyponatremia.
• Approach to a patient with hyponatremia,
• Treatment of hyponatremia (using 3% saline and pharmacotherapy of hyponatremia).
• Approach to a patient with hypernatremia.
• Treatment of hypernatremia.

6.2.2

Electrolyte Imbalance 2

Hypokalemia, Hyperkalemia

• Potassium homeostasis
• Hypokalemia – (Definition, Etiology, Diagnostic approach/algorithm, Management (Pharmacological/Non Pharmacological).
• Hyperkalemia - Definition, Etiology, Diagnostic approach/algorithm, Management (Pharmacological/Non Pharmacological).
• Hyper and hypokalemia in a palliative care setting.

6.2.3

Electrolyte Imbalance 3

Hypocalcaemia, Hypercalcemia

• Calcium and Magnesium Homeostasis.
• Definition, Etiology, Diagnostic approach/algorithm, Management (Pharmacological/Non Pharmacological),

Hypomagnesaemia, Hypomagnesaemia

specific clinical/laboratory diagnostic tests, prevention, relevance in a palliative care setting of: Hypocalcaemia /Hypercalcemia / Hypomagnesaemia /Hypomagnesaemia

6.2.4

Acid-Base Disorders

• General principles of acid-base balance
• Definitions and Stepwise approach,
• Estimating compensatory responses to primary acid-base disorder
• Differential diagnosis
• Metabolic acidosis,
• Metabolic alkalosis,
• Respiratory acidosis,
• Respiratory alkalosis

6.2.5

Urinary Tract Infections

• Definitions (Asymptomatic bacteruria, Uncomplicated UTI, Complicated UTI)
• Risk factors, symptoms and approach to a patient with complicated UTI
• Prevention and management of complicated UTI
• Catheter associated UTI (prevention and management + IDSA guidelines)
• Antimicrobials in prevention and treatment of UTI as per current guidelines
• Collecting specimens in UTI

6.2.6

Respiratory Tract Infections

• Aspiration pneumonia (risk factors, diagnosis, treatment)
• Community Acquired Pneumonia in a patient advanced illness (microbial patterns, diagnosis, treatment)
• Pseudomonas Bronchopulmonary infections
• Acute exacerbation of COPD.
• Viral and fungal lung infections

6.2.7

Gastrointestinal and Hepatobiliary infections

• Approach to a patient with diarrhea
• Common GI infections in patients with advanced illness (bacterial/viral/parasitic), [approach + diagnosis + treatment]
• Hepato-biliary infections (Cholangitis, Hepatitis, Liver abscess)
• Peritonitis
• Bacterial infections of the oral cavity.
• Oral and pharyngeal candida.

6.2.8

Skin and soft tissue

• Infected pressure sore,

infections

CNS Infections

• Infected ulcers/wounds,
• Cellulitis,
• Lymphangitis
• Herpes Zoster
• Meningitis/Meningoencephalitis

CD6.3MANAGING CO -MORBID ILLNESS IN A PALLIATIVE MEDICINE

SETTING

6.3.1

Co- morbid illness 1

• Guidelines for management of Diabetes Mellitus in Palliative Medicine setting.
• Blood sugar control based on prognosis (years, months, days)
• Diabetes Mellitus management in End of Life phase
• Pharmacological management in Type 1 and Type 2 Diabetes Mellitus
• Insulin preparations – choices, using a sliding scale
• Managing corticosteroids induced Diabetes Mellitus
• Management of Diabetic Ketoacidosis and Non Ketotic Hyperosmolar state
• Recognition and management of Hypoglycemia

6.3.2

Co- morbid illness 2

• Optimizing hypertension management and anti-hypertensive choice in palliative care setting
• Optimizing ischemic heart disease management and rationalizing use of cardiac drugs and diuretics
• Optimizing dyslipidemia and rationalizing use/stopping of lipid lowering drugs
• Optimizing use/stopping of anti-platelet drugs and anti-coagulants
• Management of other co-morbid illnesses such as (Bronchial Asthma, COPD, Hypothyroidism, Rheumatoid Arthritis etc.)

SECTION CD7: PSYCHOSOCIAL ISSUES IN PALLIATIVE MEDICINE

Sl. No

Topic

Essentials

CD 7.1 ILLNESS EXPERIENCE AND SUFFERING

7.1.1

Illness, Suffering and

Psychological issues

• Human experience of illness
• Psychological response to illness

of dying

• Defining and understanding suffering
• Triangular model of suffering
• Dimensions of patient distress/suffering in a life limiting illness context
• Dimensions of family distress/suffering in a life limiting illness context

7.1.2

Defense mechanisms and Coping Strategies

• Definition of defense mechanisms
• Classification of defense mechanisms – Primitive, Immature, Neurotic, Mature Types with examples
• Difference between defense mechanisms and coping strategies
• Coping strategies – definition, types, explanations and examples
• Coping strategies in chronic physical illnesses

7.1.3

Emotional experience of pain

• The pain experience
• Meaning of pain in terminal illness
• Psychological impact of uncontrolled pain
• Modulatory systems involved in pain pathway that influence pain perception
• Bio-psycho-social factors influencing pain perception
• Factors decreasing and increasing pain tolerance

7.1.4

Grief and Bereavement 1

• Definitions (Bereavement, Grief, Mourning, Anticipatory Grief, Pathological Grief and Disenfranchised Grief)
• Kubler Ross Model – 5 stages of grief
• Theories of grief
• Normal Grief and Clinical presentation of grief
• Factors affecting bereavement outcomes
• Typology of palliative care and bereaved families
• Recognizing those at risk of complicated grief

7.1.5

Grief and Bereavement 2

• Pathological Grief
• Clinical presentations of pathological grief
• Risk factors for complicated Grief
• Prolonged grief disorder
• Bereavement follow up and support

• Models of grief therapy
• Factors predicting outcomes of grief therapy
• Special bereavement situations

CD7.2 PSYCHIATRY OF PALLIATIVE MEDICINE

7.2.1

Distress and Adjustment disorder in Palliative Medicine

• Epidemiology of Adjustment disorder in PC
• Defining distress, NCCN distress thermometer, assessment of distress and causative factors
• Distress management
• Adjustment disorders – Pathogenesis Diagnostic criteria Clinical Course and presentation Prevention and early detection Management

7.2.2

Depression in Palliative Medicine

• Prevalence of depression in cancer, including advanced cancer, terminal illness
• Assessment – screening tools
• Diagnostic criteria
• Risk factors; Mechanisms; Impact on cancer;
• Treatment – Psychological and Psychopharmacological
• Suicide and desire for hastened death;
• Guidelines for management of depression in palliative care

7.2.3

Anxiety in Palliative Medicine

• Definition of fear and anxiety
• Screening for anxiety
• Anxiety subtypes in cancer – Generalized anxiety disorder, Panic disorder, Social anxiety disorder, Specific phobia,
• Anxiety due to gen med condition,
• Substance induced anxiety disorder,
• Anticipatory anxiety and nausea,
• Post-traumatic stress disorder;
• Assessment and Differential diagnosis
• Management – a) Psychological – Cognitive behavioral therapy, Behavioral interventions, Other b) Pharmacological

7.2.4

Dealing with personality traits/disorders in Palliative Medicine practice

• Identification of personality trait/disorder, personality characteristics, meaning of illness, Transference/Countertransference response, management of personality and illness
• Describing the above in the following

personality trait/disorder (Dependent, Obsessive compulsive disorder, Histrionic, Borderline, Narcissistic, Paranoid, Anti- social and Schizoid)

7.2.5

Dealing with patients with severe and other mental illness in Palliative Medicine practice.

• Affective disorders
• Psychotic disorders
• Substance use disorders
• Post traumatic disorders
• Intellectual disabilities
• Approach to a patient with chronic mental illness in PC practice.

7.2.6

Psychological issues in a patient with advanced malignancies

• Neuropsychiatric changes in patients with brain tumors and Leptomeningeal disease (Seizures, Loss of motor functions, Headache, alteration mental status, cognitive dysfunction, personality and behavioral changes, anxiety and mood changes and Hallucinations)
• Psychiatric symptoms and cerebral tumor location
• Psychiatric issues in other cancers – head and neck, lung, breast, gastrointestinal, prostate, Hemato-lymphoid
• Treatment related psychiatric side effects (corticosteroid euphoria, corticosteroid bipolarity, steroid dementia, steroid dependence, body image issues)

7.2.7

Dying Mind

• Twilight states
• Lightening before death
• Near death experiences
• Last words
• Terminal restlessness

CD7.3 DISTRESS, SPIRITUAL AND EXISTENTIAL ISSUES

7.3.1

Spiritual and Existential issues in Palliative Medicine

• Defining Spirituality, Concepts of Religion and Spirituality
• Understanding spiritual distress
• Spirituality Assessment and tools used in measuring spiritual distress
• Providing spiritual care (who and how)
• Components of spiritual care (Humane Presence, Listening and Acknowledging, Helping complete unfinished business,

Meaningful Communication, Sustaining Personhood and Reconnecting with the community)

• Existential distress and managing Existential issues

CD7.4 PSYCHOSOCIAL SUPPORT

7.4.1

Care giver support

• Types of caregivers
• Caregiver burden
• Tools to measure caregiver burden
• Psychosocial problems of caregivers
• Interventions to deal with family caregiver burden
• Support groups in Palliative Medicine

7.4.2

Self care

• Burnout (Definition, risk factors, markers)
• Compassion fatigue
• Burnout in PC practice and factors influencing burnout unique to PC
• Concept of self care
• Self assessment and self care plans
• Self care Protective Practices, Protective Skills and Protective Arrangements

SECTION CD8: PEDIATRIC AND GERIATRIC PALLIATIVE MEDICINE, END OF LIFE CARE

Sl. No

Topic

Essentials

CD8.1 PEDIATRIC PALLIATIVE MEDICINE

8.1.1

Introduction to Pediatric Palliative Care

• Children needing palliative care (from WHO Global Atlas of Palliative Care 2014)
• Edmarc experience
• Pediatric Palliative Care in India + Level of integration
• WHO definition of pediatric palliative care
• ACT/RCPCH pediatric palliative care (PPC) trajectory of illness (Group I to Group IV)
• Triaging in pediatric palliative care. (4 triage groups)
• Differences between adult and pediatric palliative care
• Square of care in PPC
• Barriers involved in PPC provision
• Broad format of pediatric palliative care provision (Physical, Psycho-social, Spiritual,

Advanced Care planning and Practical) – Read from Chapter 194 Declan Walsh.

• Models of care in children's palliative care (Foot prints, CHI-PACC, IPPC)

8.1.2

Pediatric Pain 1

• Etiological classification of pain in PPC
• Algorithm for evaluation of pain in the pediatric population
• Pain history taking in PPC
• Pain expression in children
• Detailed description of various age and situation specific pain assessment scales in children
• Guidelines for administering and interpreting pain assessment tools in children
• Assessment of impact of pain in children

8.1.3

Pediatric Pain 2

• Principles of pharmacological treatment of pain in children
• WHO two step ladder for pain management in children
• Using non-opioids for pain in children (Drugs, formulations and dosing)
• Using opioids for pain in children (Drugs, formulations and dosing)
• Adjuvant analgesics for managing pain in children
• Non pharmacological management of pain in children

8.1.4

Pediatric non pain symptoms

• Pediatric Delirium (Pathophysiology, etiology, clinical presentation, pediatric delirium assessment, using pCAM questionnaire in children, pediatric delirium assessment scales, pharmacological and non pharmacological management of pediatric delirium)
• Dyspnea and intractable cough in children (etiology, assessment and management)
• Assessment and management of nausea and vomiting in children.
• Assessment and management of constipation in children

8.1.5

Pediatric Palliative Care in Cancer

• Approach to a child with advanced cancer
• Supportive Care issues in Pediatric Oncology
• Palliative care in specific pediatric solid

tumors (Retinoblastoma, PNET, Neuroblastoma, bone tumors, Hepatoblastoma, Wilm's tumor etc.)

• Palliative care in specific pediatric Hemato- Lymphoid malignancies

8.1.6

Pediatric Palliative Care in Non Cancer conditions

• PPC in chronic pediatric neurodegenerative conditions
• PPC in Hemolytic Anemia (Thalassemia and Sickle Cell Disease)
• PPC in Cystic Fibrosis
• PPC in Congenital Heart Diseases
• PPC in Inborn errors of metabolism and chromosomal abnormalities

8.1.7

Psychosocial, communication and ethical issues specific to Pediatric Palliative Care

• Children's views of death
• Communication with children in PPC
• Impact of serious life limiting illness on family - parents and siblings
• Psychological adaptation of the dying child
• Guidelines for working with the dying child
• Decision-making and ethical issues in pediatric palliative care
• Factors affecting bereavement and bereavement support and interventions

8.1.8

Adolescent Palliative Medicine

• Classification of adolescents based on physical and cognitive states
• Life limiting conditions affecting adolescents and young adults needing palliative medicine.
• Specific palliative care needs in early/mid/late adolescents
• Psycho-social issues specific to Adolescent Palliative Medicine
• Manifestations of grief in adolescents age group

CD8.2 GERIATRIC PALLIATIVE MEDICINE

8.2.1

Aging

• Sociodemographics of Aging with emphasis on developing countries;
• Theories and Biology of ageing
• Physiology of aging
• Implications of aging in health care and palliative care

8.2.2

Frailty

• Definition
• Prevalence

• Pathophysiology and clinical features
• Tools to measure frailty
• Risk factors for falls
• Comprehensive assessment and interventions

8.2.3

Management of older individuals needing Palliative Care

• Broad dimensions of problems in elderly population
• Geriatric assessment and geriatric assessment tools
• Common medical problems in elderly and their management
• Common psychological/psychiatric morbidity in elderly
• Practical, Social and Emotional issues
• Decision making, goals of care and end of life care in older individuals receiving PC

CD8.3 END OF LIFE CARE

8.3.1

End of Life Care 1

• Estimating EOLC needs in the community.
• Gaps in EOLC needs in India across various clinical setting.
• Prognostication
• Principles of Good Death
• Components of Good Death
• Steps involved in providing Good End of Life Care (1. Recognizing the dying process

2. End of Life Decision Making 3. Initiation of EOLC 4. Process of EOLC 5. After death Care)

• Recognizing the dying process
• EOLC decision making (Timing, Decision Makers, Shared Decision Making)

8.3.2

End of Life Care 2

• Ethical aspects specific to EOLC (Autonomy and Beneficence, Autonomy and Non maleficence, Non abandonment and Non Maleficence, Disclosure and beneficence, Fair allocation of societal resources).
• Special ethical situations (Futility of treatment and Euthanasia)
• Legal aspects of EOL as applicable to India

8.3.3

End of Life Care 3

• Principles of EOLC symptom management.
• 6 step EOLC approach (Identify – Assess – Plan – Provide – Reassess – Reflect).
• Respiratory secretions in EOLC.
• Nursing Interventions in EOLC.
• Palliative Sedation.
• Silver hour

• End of Life Care process and pathways

8.3.4

End of Life Care 4

• Principles of after death care.
• 4 step approach in verification and certification of death (verification – certification – reporting – registration).
• International guidelines for verification of death. Verification of death in primary care, hospital, ICU and comatose patients.
• Registration of Births and Death Act 1969.
• Writing a death certificate. Death Certificate form. When not to issue death certificate.
• 6 recommendations of IAPC consensus position statement on EOLC policy.
• IAPC + ISSCM joint society 12 step guidelines on EOLC.

SECTION CD9: SPECIAL TOPICS IN PALLIATIVE MEDICINE

Sl. No

Topic

Essentials

CD9.1 SPECIAL TOPICS IN PALLIATIVE MEDICINE

9.1.1

Sleep in Palliative Medicine

• Sleep physiology
• Sleep theories
• Sleep disturbances in advanced cancer
• Tools to measure sleep related parameters;
• Management of sleep disorders

9.1.2

Body image and Sexuality in Palliative Medicine

• Body image and sexuality in different illnesses
• Sexuality in cancer
• Psychosocial predictors of sexual functioning after cancer
• Sexual history taking
• PLISSIT model
• Interventions to improve sexual functioning

9.1.3

Ethical Issues in Palliative Medicine 1 (Basics)

• Principles and theories
• Cardinal principles of Medical Ethics and its application (Autonomy, Beneficence, Non Maleficence, Justice)
• Decision making capacity/Surrogate Decision making
• Confidentiality
• Informed Consent

9.1.4

Ethical Issues in

• Limitation of disease modifying treatment

Palliative Medicine 2 (Special situations)

• Withholding and withdrawing of life sustaining treatment
• Nutrition and Hydration
• Ethical situations in end of life decision making and end of life care
• Conflict and Collusions
• Palliative care research

9.1.5

Advanced Directives and Advanced Care Planning

• Definition of Advance Directives (AD)
• Types of AD
• Components of AD
• Evidence for AD
• Definition of Advance Care Planning (ACP)
• Differences between AD and ACP
• Components of effective ACP
• Evidence for ACP

9.1.6

Communication Skills training 1

(Basics of Communication and Breaking Bad News)

• Basics of communication
• Patient centered communication (Goals of patient centered communication, Active Listening, Pre-requisites for good communications, Outcomes of good communication)
• Verbal and Nonverbal behaviors
• Basics of bad news and truth telling
• SPIKES Protocol/CLASS Approach in Breaking Bad News (BBN)
• Unhelpful statements/Avoiding Pitfalls/Barriers and Reactions to BBN

(All these discussions should be undertaken along with Role Play)

9.1.7

Communication Skills training 2

(Dealing with Common Communication Issues)

• Informed consent
• Decision making
• Uncertainty
• Denial
• Collusion
• Conflict
• Anger
• Medical errors

(All these discussions should be undertaken along with Role Play)

9.1.8

Communication Skills training 3

(Advanced Medical

• Cessation of disease modifying care
• Transition of care
• Discussing prognosis and life expectancy

Communication Situations)

• Discussing future symptoms
• Discussing goals of care
• Discussing life sustaining treatment
• End of life care communication

(All these discussions should be undertaken along with Role Play)

CD9.2 PALLIATIVE MEDICINE IN SPECIAL SITUATIONS

9.2.1

Palliative Medicine in Bone Marrow/Stem Cell Transplantation

• Physical symptoms specific to stem cell transplantation
• Psychosocial issues specific to stem cell transplantation
• Management of physical symptoms – Rational Pharmacology specific to SCT
• Management of psychosocial issues – Rational Psychopharmacology specific to SCT
• Communication issues in SCT
• Transitions of care and End of Life in SCT.

9.2.2

Palliative Medicine in Intensive Care

• Situations in intensive care setting where palliative care is appropriate
• Approach, decision making and transitions of care in ICU
• Communication with families regarding palliative care in ICU setting
• Ethical and legal considerations of limiting life sustaining treatment in ICU
• Guidelines for limiting life sustaining treatment and providing palliative care/end of life care in ICU

9.2.3

Perinatal Palliative Medicine

• Definition and scope of perinatal palliative medicine
• Conditions suitable for perinatal palliative medicine
• Pain assessment in fetuses and newborn
• Stages of planning in perinatal palliative medicine (Antenatal planning, pre birth care, intrapartum and postpartum care)
• End of life care decisions in babies with adverse prognosis

CD9.3 PROCEDURES, INTERVENTIONAL TECHNIQUES IN PALLIATIVE

MEDICINE

9.3.1

Procedures and

• Parenteral opioid infusions, setting up a

Interventional techniques in Palliative Medicine 1

syringe driver, syringe driver compatibility, dosing and titration, monitoring, anticipating complications and mitigation mechanisms

• Epidural and Intrathecal Analgesia, technical aspects of procedure, dosing and titration, managing a patient with Epidural and Intrathecal catheter, Early and Late complications of intrathecal and epidural analgesia
• Site specific neurolytic procedures

9.3.2

Procedures and Interventional techniques in Palliative Medicine 2

• Oxygen, Oxygen delivery systems, cannula masks and venture, non invasive ventilation, Tracheostomy
• Abdominal paracentesis, pleurocentesis, pericadiocentesis, Intercostal drains
• Nasogastric/Nasojejunal tubes, Percutaneous gastrostomy, Feeding Jejunostomy, peritoneal catheter for ascetic tap, percutaneous biliary drainage and other stenting procedures
• Urinary catheters including suprapubic, Percutaneous nephrostomy, DJ stenting

CD 9.4 INTEGRATIVE MEDICINE IN PALLIATIVE MEDICINE

9.4.1

Integrative Medicine1

• Integrative Medicine Classification
• Integrative Medicine -PC Inter-phase
• Integrative Medicine interventions

9.4.2

Integrative Medicine 2

• Integrative Medicine in Pain Management
• Integrative Medicine in Management of Nausea
• Integrative Medicine in Management of Dyspnea
• Integrative Medicine in Management of Fatigue, Anorexia Cachexia Syndrome
• Integrative Medicine in Anxiety and Depression
• Evidence based clinical practice guidelines for management for Integrative Oncology, Integrative Medicine and Botanical preparations

SECTION CD10: NURSING AND REHABILITATIVE CARE IN PALLIATIVE MEDICINE

Sl. No

Topic

Essentials

CD10.1 NURSING CARE IN PALLIATIVE MEDICINE

10.1.1

Care of Stomas 1 (Colostomy and Ileostomy)

• Classification and detailed description of each types)

(Temporary Colostomy, Decompressive Colostomy, Diverting Colostomy, Permanent Colostomy, Ileostomy)

• Management of a patient with colostomy and ileostomy

(Pre-op education, facilitating adaptation, pouching, odor and gas management, Activities in a patient with colostomy-ADLs, sexual activity, travel, sports etc.)

• Dietary management of a patient with colostomy and ileostomy
• Ileostomy care and special issues in Ileostomy care
• Colostomy irrigation
• Complications of colostomy and ileostomy and management of complications
• Patient education and information

10.1.2

Care of Stomas 2 (Tracheostomy, Urostomy, Gastrostomy)

• Timing and indications for tracheostomy
• Techniques and contraindications for tracheostomy
• Immediate post-op care in tracheostomy
• Technique of changing the tracheostomy tube

– things to look for

• Decannulation
• Complications in a patient with Tracheostomy
• Nursing care of a patient with tracheostomy
• Patient education and information
• Urinary diversion – overview and indications
• Ileal conduit and continent cutaneous diversions
• Complications of urinary diversion procedures
• Nursing care of a patient with ileal conduit
• Care of a patient with percutaneous nephrostomy.
• Care of Gastrostomy and Jejunostomy
• Care of a patient with Nasogastric and Nasojejunal tube.

10.1.3

Lymphedema

• Anatomy and Physiology of Lymphatic system
• Pathophysiology and classification
• Cancer associated Lymphedema

• Clinical features and staging of Lymphedema
• Approach to a patient with Lymphedema (History and Examination)
• Clinical and anthropometric measurements and relevant investigations
• Differential diagnosis and complications
• Prevention of Lymphedema
• Treatment of Lymphedema
• Complete Decongestive Therapy (CDT) in Treatment Phase and Maintenance Phase
• Components of CDT (Manual lymphatic draining, compression bandaging and garments, Exercise and Elevation, Skin care)
• Devices used in management of Lymphedema
• Pharmacological treatment of lymphedema

10.1.4

Malignant Wounds, Chronic Malignant/Non Malignant Fistulas and Sinuses

• Tumor Necrosis (Definition, Pathophysiology, Assessment and Management)
• Comprehensive assessment of a malignant wound
• Management of a malignant wound (Exudate, Odor, Bleeding, Infection, Pain)
• Myiasis (Maggots)
• Topical dressings and drugs used in management of malignant wound
• Fistulas (Definition, Pathophysiology, Assessment and Management)
• Sinuses (Assessment and Management)

10.1.5

Pressure Ulcers

• Pathogenesis and risk factors for pressure ulcers
• Risk prediction scales (Norton and Braden)
• Clinical features
• NPUAP staging
• Stage wise management of pressure ulcers
• Local measures and dressing used
• Role of surgical interventions in pressure ulcers
• Other treatment techniques (negative pressure therapy, hyperbaric oxygen, ultrasound, electrical stimulation)
• Prevention of pressure ulcers (pressure redistribution techniques, positioning techniques, skin care, other supportive techniques-mobility/nutrition etc.)

• Infectious and non-infectious complications of pressure ulcers
• Patient education and information

10.1.6

Bladder and Catheter Care

• Catheter associated UTI (Risks, mechanisms, Diagnostic criteria, Clinical features, common organisms, complications)
• Management of catheter associated UTI (Stepwise protocol, Antibiotic regimes, Supportive treatment)
• Common types of catheters and bags (Catheter makes, balloon types, balloon sizes, catheter sizes and diameters, bags and insertion gel)
• Technique of insertion and removal
• Types of catheterization (short/intermediate and long term)
• Catheterization methods (Intermittent, indwelling, suprapubic, condom)
• Problems associated with long term catheter
• Principles of care of urinary catheter
• Patient education and information

10.1.7

Oral Care 1

• Clinical Assessment of Oral Cavity – 8 component assessment (Voice, Swallowing, Lips, Tongue, Saliva, Gums, Teeth/Dentures, Mucus Membrane)
• Five stage model of Oral Mucositis (OM)
• Causes and etiopathogenesis of OM
• WHO Scale/NCI-CTC-AE Grade of OM
• Clinical Stages of OM
• Management of OM (Stepped Protocol – Basic Oral Care, Bland Rinses, Topical Analgesics/Anesthetics/Mucosal Coating agents, Systemic Analgesics)
• Combination Mouth Washes (Miracle Mouth Wash 1 and 2/Magic Mouth Wash etc.)
• Prevention of OM

10.1.8

Oral Care 2

• Halitosis (3 stage scale/Organoleptic Scoring Scale, Assessment and Management)
• Xerostomia (Definition, Pathophysiology, Etiology, Xerostomia index, Sialagogues, Non Pharmacological Management)
• Sialorrhea (Assessment and Management)
• Dysgeusia (Assessment and Management)

• Oral Candida (Causative organisms, Clinical types, Clinical Presentation, Treatment and Prevention)
• Bacterial and viral infections of oral cavity

10.1.9

Incontinence Care

• Bladder physiology including nerve supply
• Urinary Incontinence (Definition, Pathophysiology and Epidemiology)
• Clinical types of Urinary Incontinence with detailed description of each type (Urge, Stress, Mixed, Overflow, Continuous)
• Algorithm of assessment and management of Urinary Incontinence (including etiology for each type)
• Pharmacological management of Urinary Incontinence
• Overall management of each type of urinary incontinence
• Fecal incontinence (Epidemiology, pathophysiology, clinical presentation)
• Algorithm for evaluation of a patient with fecal incontinence
• Management of fecal incontinence and general bowel management
• Management of a patient with Vesico- Vaginal fistula and Recto-Vaginal fistula

10.1.10

Nursing Care in Bedridden patients and patients with altered mental status

• Common nursing issues in a bedridden patient
• Common nursing issues in a unconscious patient
• Assessment and management of nutritional needs, airway protection and prevention of aspiration, skin care, positioning, bowel management, mucosal care, prevention of delirium and depression, preventing infections, safety and fall prevention

10.1.11

Nursing Care in End of Life

• Assessment of end of life care symptoms
• Assessment of non physical needs in end of life
• Anticipatory prescription and prompt response to symptoms
• Non pharmacological management of respiratory secretions, pain, restlessness, dyspnea
• CAM therapies in end of life
• After death care

CD10.2 REHABILITATIVE CARE IN PALLIATIVE MEDICINE

10.2.1

Quality of Life, Performance Status and Mobility

• Definition and structure of quality of life
• Multidimensional assessment of QOL
• Health related QOL in PC
• Karnofsky Performance Scale (Uses, Structure, Validity)
• Eastern Cooperative Oncology Group (ECOG) Scale (Uses, Structure, Validity)
• Barthel index

10.2.2

Medical Rehabilitation of a Palliative Care Patient 1

• Rehabilitation in Palliative Care
• Rehabilitation team
• Needs assessment, integration, goal setting and delivery
• Pulmonary Rehabilitation
• Speech and language rehabilitation
• Swallowing rehabilitation

10.2.3

Medical Rehabilitation of a Palliative Care Patient 2

• Rehabilitation of palliative care patients with motor deficits
• Rehabilitation of palliative care patients with sensory deficits
• Rehabilitation of palliative care patients with cranial nerve deficits
• Rehabilitation of palliative care patients with cognitive dysfunction
• Rehabilitation of palliative care patients with deconditioning

10.2.4

Nutrition and Hydration in Palliative Medicine

• Nutrition and cancer/chronic illness
• Nutritional and Hydration assessment
• Principles of nutrition therapy (Indications and routes)
• Enteral and parenteral nutrition in terminally ill patient
• Hydration in a terminally ill patient.

AD1. PALLIATIVE CARE PRINCIPLES

AD1.1

Recognizes pain, symptoms and suffering in patients with advanced life

limiting illness

AD1.2

Recognizes the need for relief of psychosocial, spiritual and existential

suffering

AD1.3

Recognizes the need for appropriate care and support for the family and caregivers

AD1.4

Recognizes that the care is person centered, personalized and holistic aiming

to improve physical symptoms, suffering and quality of life.

AD1.5

Recognizes the vast unmet palliative care needs in the population

AD1.6

Understands principles of palliative care and its application

AD1.7

Recognizes the need to advocate for the patients needing palliative care

AD1.8

Understands various modes and models of palliative care delivery

AD1.9

Recognizes the need for palliative care policy at institutional/national level

and recognizes the need for developing the same.

AD1.10

Recognizes the need for palliative care quality standards and implementation

of the same

AD2. PAIN AND SYMPTOM MANAGEMENT

AD2.1

Demonstrates interest and openness in dealing with pain and symptoms

AD2.2

Exhibits leadership and responsibility in dealing with patients with poorly

controlled and intractable pain and symptoms

AD2.3

Exhibits safe prescription writing, exhibits care while prescribing medications

for pain and symptom control and recognizes the need to identify aberrant drug use/drug diversion

AD2.4

Recognizes the role of cognitive, emotional, and spiritual factors in the

symptom experience

AD2.5

Recognize the impact of pain and physical symptoms on activities of daily

living, sleep, mood, sexual activity and other social domains

AD2.6

Recognizes the value of a multidisciplinary approach to symptom

management

AD2.7

Recognizes and initiates appropriate referral to other pain management

services as needed

AD2.8

Recognizes the role and importance of parenteral and interventional pain

management in patients with intractable pain.

AD2.9

Recognizes the need to initiate palliative sedation in suitable patients with

intractable symptoms

AD2.10

Exhibits a compassionate attitude towards the patients with pain and

symptoms

AD3. CLINICAL EXPERT

AD3.1

Recognizes palliative care needs in a patient with advanced cancer

AD3.2

Expresses the palliative care needs of patients with advanced cancer to the

treating oncologist and advocates for early palliative care referral

AD3.3

Recognizes palliative care needs in non-oncology conditions such as end

stage organ failures, advanced HIV/AIDS, chronic neurodegenerative conditions etc.

AD3.4

Expresses the palliative care needs of patients with advanced non-oncological

conditions to the concerned specialists and advocates importance of palliative

care referral

AD3.5

Recognizes supportive care needs in patients with advanced life limiting illness and understands importance of supportive care in length and quality of

life

AD3.6

Recognizes complications in patients with advanced life limiting illness and initiates appropriate management after thorough consideration of benefits and

futility

AD3.7

Recognizes comorbid conditions in patients with advanced life limiting illness

and provides appropriate management or referral to the concerned specialist

AD3.8

Recognizes emergencies in palliative care

AD3.9

Recognizes the importance of managing palliative care emergencies and

provides appropriate situation specific care after thorough consideration of benefits and futility

AD3.10

Recognizes and initiate appropriate referral to other specialist services disease

management provided such referral positively impacts symptom control and quality of life.

AD4. PSYCHOSOCIAL, EMOTIONAL AND SPIRITUAL SUPPORT

AD4.1

Recognizes the need for comprehensive assessment of socioeconomic status,

caregiver support, social and financial support and living conditions of the patient and family

AD4.2

Understands and evaluates psychological and emotional concerns of patients

and their families

AD4.3

Recognizes distress and exhibits an empathic approach to patient and family

AD4.4

Recognizes the need for involvement of other appropriate health

professionals, e.g. social workers/psychologists/counselors, as needed in assessment and management of distress

AD4.5

Recognizes anxiety, depression and other psychiatric morbidity prior and

occurring during illness

AD4.6

Recognizes the need to consult with psychiatric services when appropriate

AD4.7

Exhibits holistic approach towards care of patients with psychiatric

complications

AD4.8

Recognizes patients with intentional self harm behavior and suicidal ideations

AD4.9

Recognizes that spirituality is an integral part of a patient's experience

AD4.10

Recognizes that spiritual pain can contribute to suffering and recognizes the

contribution of the spirituality to hopelessness and meaning of life

AD5. MULTIDISCIPLINARY CARE

AD5.1

Chooses to be a team player and openly supports team activity

AD5.2

Recognizes the importance of team cohesiveness and strives towards same

AD5.3

Exhibits participation in a multidisciplinary team and recognizes importance

and contributions of each team member

AD5.4

Exhibits contribution towards multidisciplinary team meeting and recognizes the need to work cohesively with other member team members to achieve a

common goal.

AD5.5

Recognizes the need to participate in interdisciplinary team meetings such as

disease management groups, tumor board meeting, joint clinics etc.

AD5.6

Recognizes the need to advocate for patients in interdisciplinary team

meetings and advocate for patients with other specialists.

AD5.7

Exhibits consideration and respect for opinions of members of

multidisciplinary and interdisciplinary teams

AD5.8

Recognizes the need for educational activities within the multidisciplinary

team

AD5.9

Recognizes need to create research opportunities within

multidisciplinary/interdisciplinary team

AD5.10

Recognizes the need for team building exercises

AD6. SHARED DECISION MAKING

AD6.1

Exhibits a non-judgmental attitude towards value and belief systems of

patients and families

AD6.2

Recognizes the need to participate in shared decision-making to ensure that

outcomes are compatible with the values and belief systems of patients and families.

AD6.3

Recognizes that relationships with patients and their families based on mutual

understanding, trust, respect, and empathy facilitate good decision making

AD6.4

Recognizes importance of good decision-making and adverse outcomes of

poor decision-making resulting in inappropriate care.

AD6.5

Recognizes the need to discuss possible therapies available to a patient in an

open and non-judgmental manner

AD6.6

Recognizes the limitations as well as the strengths of curative and disease modifying treatment in patients with progressive, life-threatening illness

AD6.7

Recognizes the need to participate in important decision-making situations such as cessation of disease modifying treatment, transitions of care,

discussion of goals of care etc.

AD6.8

Recognizes the need to participate and provide input during advanced care

planning.

AD6.9

Recognizes the need to participate in discussions around withholding and

withdrawing life support

AD6.10

Recognizes the need to participate in end of life care decision making

AD7. COMMUNICATION

AD7.1

Exhibits participation in honest, accurate health related information sharing

in a sensitive and suitable manner

AD7.2

Recognizes that being a good communicator is essential to practice

effectively in Palliative Medicine

AD7.3

Exhibits effective and sensitive listening skills

AD7.4

Recognizes the importance and timing of breaking bad news and knows

when not to discuss these issues.

AD7.5

Exhibits participation in discussion of emotional and existential issues

AD7.6

Exhibits competence and sensitivity in discussing transitions, palliative care

and end-of-life issues.

AD7.7

Exhibits willingness to talk openly about death and dying with patients,

family, other health professionals, and the general community

AD7.8

Exhibits leadership in handling complex and advanced communication

related issues

AD7.9

Recognizes the importance of patient confidentiality and the conflict between confidentiality and disclosure.

AD7.10

Recognizes the value of self evaluation and finessing of one's own

communication skills

AD8. PEDIATRIC AND GERIATRIC CARE

AD8.1

Recognizes varied presentation of pain and symptoms in children in different age groups

AD8.2

Recognizes varied physical, emotional and psychological needs of children

and adolescents in different age group

AD8.3

Recognizes developmental influences on pain assessment and management

AD8.4

Recognizes the need for varied communication approach in children in

different age groups

AD8.5

Recognize importance of communication with parents/grandparents/siblings and extended family

AD8.6

Recognizes how pediatric palliative care differs from adult palliative care

AD8.7

Recognizes the importance of working in a pediatric multidisciplinary team

AD8.8

Recognizes the multiple dimensions of old age problem

AD8.9

Recognizes frailty, disability, physical and psychosocial needs of older

individuals

AD8.10

Recognizes the importance of preserving functionality, preventing

complications, managing comorbidity and maintaining dignity and quality of life.

AD9.1

Recognizes the terminal phase

AD9.2

Exhibits compassionate care of dying patients and their families

AD9.3

Exhibits readiness to continually care for the dying person and support their

family

AD9.4

Exhibits a considerate, holistic end of life care approach

AD9.5

Recognizes the emotional challenges, grief and loss in themselves, other staff

and families

AD9.6

Recognizes end of life symptoms and initiates appropriate management

AD9.7

Recognizes non physical needs during end of life and recognizes the

spirituality of the dying person

AD9.8

Recognizes the importance of advanced sensitive communication during end

of life phase

AD9.9

Exhibits respect for the body after death, supporting individual religious and

cultural practices

AD9.10

Recognizes a need for an improved community awareness of end of life care

and recognizes a need for institutional/national end of life care policy.

AD10. PROFESSIONALISM AND ALTRUISM

AD10.1

Recognizes limitations of self and recognizes need to seek appropriate

help/support when required

AD10.2

Recognizes the need to participate in personal reflection and exercise mindful

practice

AD10.3

Exhibits willingness to acknowledge one's own potential issues of loss and

grief

AD10.4

Recognizes care boundaries, limitations of care and need to manage

expectations.

AD10.5

Exhibits appropriate respect for the opinions of colleagues while advocating

for palliative care

AD10.6

Exhibits leadership but also respect the leadership of others within the

interdisciplinary palliative care team when appropriate

AD10.7

Exhibits leadership and willingness to advocate for the socially disadvantaged

and vulnerable population needing/receiving palliative care

AD10.8

Recognizes the need to empower patients and their families facing life

limiting/terminal illness

AD10.9

Recognizes burn out symptoms in self and amongst members of the team and

institutes early mitigation measures

AD10.10

Recognizes the importance of self care and extend care to other members of

the team

PD1.1

Able to establish rapport and therapeutic bonding with patients of different ages, gender, religious and cultural background, socioeconomic groups, and

various illnesses/stages in illness trajectory

PD1.2

Able to obtain comprehensive and relevant history from patients, their

families and referring teams

PD1.3

Able to comprehend patient's and family wishes/preferences regarding information sharing and the extent of information they would like to receive

PD1.4

Able to break bad news and convey other health related information to patient

and their family in a sensitive and caring manner

PD1.5

Able to comprehend patient's understanding of information received, and

respond to the reactions and clarify any misunderstandings

PD1.6

Able to handle complex communication related issues such as denial, conflict,

collusion etc. within the family in a sensitive, non judgmental, culturally appropriate and respectful manner

PD1.7

Able to take lead in advanced medical communication related issues such as

cessation of disease modifying treatment, transition of care, goals of care etc.

PD1.8

Able to overcome barriers related to communication

PD1.9

Able to communicate clearly and effectively within the interdisciplinary/

multidisciplinary teams, referring physician's family physicians such that appropriateness and continuity of care is maintained.

PD1.10

Able to maintain clear, concise, accurate medical records

PD2. DECISION MAKING SKILLS

PD2.1

Able to assess the extent to which patient and caregivers would like to be part

of decision making.

PD2.2

Able to understand patient's and caregivers expectations, wishes and

preferences regarding management of the illness at hand and its complications

PD2.3

Able to facilitate patient and caregiver's participation in important treatment

relate decision-making and care process.

PD2.4

Able to discuss treatment options, its continuation and cessation, alternatives to treatment with patient and caregiver so that they are able to make informed

decisions

PD2.5

Able to ascertain patient and caregivers understanding of illness, clinical

outcomes and prognosis to facilitate appropriate future care.

PD2.6

Able to conduct a family meeting ensuring participation of patient/care givers and members of interdisciplinary/multidisciplinary team to facilitate

informed/shared decision-making.

PD2.7

Able to take lead in important decision making situations like cessation of

disease modifying treatment and transition of care process

PD2.8

Able to provide input during Advanced Care Planning

PD2.9

Able to take lead during discussion and decision making during

withholding/withdrawing life sustaining treatment and cessation of supportive

care treatment

PD2.10

Able to take lead during end of life discussion and decision-making.

PD3. PAIN AND SYMPTOM MANAGEMENT SKILLS

PD3.1

Able to perform a thorough history and examination and detailed clinical

assessment of pain and other symptoms

PD3.2

Able to assess pain and other symptoms in patients from different age groups, socio-cultural and religious backgrounds, clinical and mental status and

disease states

PD3.3

Able to relate pain and other symptoms to underlying pathophysiological mechanisms and plan rational pharmacological and non-pharmacological

treatment

PD3.4

Able to rationalize and choose appropriate investigations in patients with pain

and other symptoms, if there is scope to mitigate the symptom(s) or avoid complications

PD3.5

Able to plan treatment for pain and symptoms in the context of disease status,

prognosis, appropriateness and patient and family preferences and wishes

PD3.6

Able to choose pharmacological treatment of pain and other symptoms based

on the age, renal and hepatic parameters, response, tolerance and adverse effects.

PD3.7

Able to choose right patients for anti-cancer therapies and other disease

modification treatments for pain and symptom control and improved quality of life.

PD3.8

Able to handle/use parenteral strong opioids and administer opioids for pain control through subcutaneous and intravenous routes.

PD3.9

Able to mix drugs in a syringe driver, know compatibilities during drug mixing and able to titrate the doses to achieve optimal pain and symptom control

PD3.10

Able to manage a patient with an epidural and intrathecal catheter and able to

assist/perform simple neurolytic procedure.

PD4. SUPPORTIVE CARE AND DISEASE MANAGEMENT SKILLS

PD4.1

Able to know the natural history of cancer, epidemiology, behavior, anti- cancer therapies, transition points, palliative phase, non responsive to

treatment and stopping treatment to facilitate early and appropriate referral.

PD4.2

Able to understand cancer illness trajectory and able estimate prognosis in a

patient with advanced cancer

PD4.3

Able to initiate referral for disease modifying treatment or management of complications to a concerned specialist with a goal of improved symptom

control and betterment of quality of life.

PD4.4

Able to guide families regarding newer anti-cancer therapies/trial

treatments/Integrative Medicine therapies.

PD4.5

Able to meet palliative care needs of end stage organ failures such as advanced congestive heart failure, advanced chronic obstructive lung disease, end stage chronic kidney disease etc.

PD4.6

Able to meet palliative care needs of patients with advanced HIV/AIDS

PD4.7

Able to meet palliative care needs of patients with chronic neuro-degenerative

conditions such as Dementia, Motor Neuron Diseases etc.

PD4.8

Able to manage emergencies and complications related to the disease/disease progression such as malignant spinal cord compression, malignant superior venacaval obstruction, airway obstruction, hemorrhage etc. in a way that positively influences illness trajectory/life and be aware of situations when

management of these are futile.

PD4.9

Able to manage concurrent illnesses such as infections/sepsis, metabolic disturbances, anemia, thrombosis etc. in a way that positively influences illness trajectory/life and be aware of situations when management of these

are futile.

PD4.10

Able to manage co-morbid illnesses such as hypertension, diabetes mellitus,

ischemic heart disease etc. and able initiate referral to concerned specialist as required.

PD5. PSYCHOSOCIAL SUPPORT SKILLS

PD5.1

Able to assess and appraise patient's psychological, social, financial, spiritual

and existential concerns

PD5.2

Able to identify and quantify distress and provide support to patients and

families

PD5.3

Able to handle distressing emotions, anger, blame, guilt etc. in patients and

their families respectfully and sensitively in a non judgmental manner

PD5.4

Able to identify spiritual issues and perform assessment of spiritual concerns

PD5.5

Able to identify spiritual distress and spiritual nature of suffering and provide

spiritual care by self or with the help of chaplain

PD5.6

Able to perform detailed mental status examination and identify and manage

adjustment disorders, anxiety and depression

PD5.7

Able to assess a patient with psychiatric morbidly, seek help from the

psychiatrist/clinical psychologist and formulate a management plan

PD5.8

Able to identify patients/caregivers at risk of intentional self harm and with

suicidal ideations and initiate a emergency management plan

PD5.9

Able to explore and discuss issues related to body image changes/disfigurement and sexuality in a sensitive and respectful manner

PD5.10

Able to counsel the patients and caregivers in a scientific and rational manner

addressing their needs.

PD6.1

Able to facilitate creation of a multidisciplinary team comprising of health professionals from a range of disciplines and expertise

PD6.2

Able to work as a member of team and able to be a team player.

PD6.3

Able to take up leadership, ensure participation and coordinated work of

members of multidisciplinary team to achieve a common goal

PD6.4

Able to recognize value and contributions of members of multidisciplinary

team and able to delegate responsibilities.

PD6.5

Able to respect opinions of the members of the multidisciplinary team and able to resolve team conflicts.

PD6.6

Able to attend interdisciplinary meetings such as tumor board meetings,

disease management group meetings, joint clinics etc.

PD6.7

Able to make relatable contributions to these interdisciplinary meetings and

advocating for appropriate care and palliative care

PD6.8

Able to respect opinions of the other specialists and also respectfully disagree

the decisions of the other clinicians if they are not in the best interest of the patient.

PD6.9

Able to carry out education, view sharing and other team building exercises.

PD6.10

Able to facilitate research opportunities in a multidisciplinary and

interdisciplinary setting.

PD7. END OF LIFE CARE SKILLS

PD7.1

Able to recognize terminal phase and diagnose dying. Able to assist peers to

recognize dying and facilitate appropriate care

PD7.2

Able to participate in end of life decision-making with the other specialists and arrive at consensus, appropriate and patient centered clinical decision and

goals of care.

PD7.3

Able to participate in end of life decision-making with the families,

empowering shared decision making and able to communicate effectively end of life concerns and prognosis.

PD7.4

Able to discuss with patients and families regarding preferred place of care.

PD7.5

Able to assess appropriateness of initiation of end of life care process. Able to

understand, use, educate and implement end of life care pathway and process.

PD7.6

Able to understand and apply ethical and legal aspects pertaining to end of life

care.

PD7.7

Able to effectively assess physical and non-physical needs of a dying person

and provide appropriate pharmacological, nursing and psychosocial support.

PD7.8

Able to identify families who will be at high risk of bereavement.

PD7.9

Able to discuss, educate and advocate for end of life care with the peers,

institution and community at large.

PD7.10

Able to advocate for hospital end of life care policy and hospital directives for

withholding/withdrawing life support.

PD8.1

Able to perform insertion of subcutaneous and intravenous lines, able to administer medications for pain and symptom control through subcutaneous

and intravenous route

PD8.2

Able to set up a syringe driver, calculate doses, mix drugs, know

compatibility and administer medications as a continuous infusion.

PD8.3

Able to handle various types of syringe drivers, PCA pumps, continuous

ambulatory drug devices etc. knows how to handle these instruments.

PD8.4

Able to perform diagnostic and therapeutic paracentesis and pleurocentesis.

PD8.5

Able to insert nasogastric and assisted Nasojejunal tubes. Able to insert

indwelling urinary catheters and care for a patient with a catheter.

PD8.6

Able to recognize and manage a pressure ulcer and malignant wound. Able to do wound dressing in different kinds of wounds with various dressing. Able to

manage complications of wounds such as bleeding, foul smell, Myiasis etc.

PD8.7

Able to manage and care for a patient with stoma: Tracheostomy Care, Gastrostomy, and Colostomy Care. Able to perform high up enemas and

colostomy irrigation

PD8.8

Able to use oxygen, nebulizers and other non-invasive respiratory support

devices

PD8.9

Able to manage a patient with Lymphedema. Able to perform complete

decongestive therapy using Lymphedema Bandage, Massage and Exercise.

PD8.10

Able to care for the dying patients, plan and administer palliative sedation in

dying patients with intractable symptoms.

PD9. QUALITY ASSURANCE, EDUCATION AND RESEARCH SKILLS

PD9.1

Able to participate in departmental quality assurance activities and implement

quality improvement strategies such as audit processes

PD9.2

Able to monitor effectiveness of the program and reduce lapses in care

process and medical errors

PD9.3

Able to develop departmental/institutional clinical management algorithms

and standard operating procedures.

PD9.4

Able to provide high level of teaching skill and actively participate in

departmental and hospital educational programs

PD9.5

Able to involve actively in conducting sensitization programs, certificate

courses, CMEs and national/international conferences

PD9.6

Able to initiate/encourage research in Palliative Care

PD9.7

Able to seek permission from institutional review board and undertake ethical

research

PD9.8

Able to voluntarily express self-awareness of conflict of interest

PD9.9

Able to conduct blinded randomized studies and observational

PD9.10

Able to critically analyze RCTs, systematic reviews and exhibit evidence

based practice