Learning Objectives

UNIPAC 1 The Hospice and Palliative Care Approach to Serious Illness

Upon completion of this module, a practitioner should be better able to

• articulate key aspects and principles of palliative care
• identify key barriers to providing palliative care
• describe models of palliative care in various settings
• articulate key aspects of hospice care
• describe the role of the physician and nurse practitioner in hospice and palliative care
• describe the role of quality assurance in hospice and palliative care and identify key measurement domains
• identify key issues in research in palliative care.

UNIPAC 2 Alleviating Psychological and Spiritual Pain

• identify common reactions to loss
• use predictors to assess the likelihood of complicated reactions to loss
• use effective interventions to re-establish a patient's sense of purpose
• use effective interventions to enhance a patient's sense of efficacy
• use effective interventions to foster hope
• assess and manage anxiety and depression with pharmacological and nonpharmacological interventions
• differentiate complicated and uncomplicated grief reactions
• assess for spiritual pain and provide effective basic interventions
• involve other team members in alleviating psychological and spiritual pain.

UNIPAC 3 Assessing and Treating Pain

• assess for the presence of cancer-related and noncancer-related (nonmalignant) pain
• identify physical, emotional, social, and spiritual aspects of pain and suffering
• differentiate nociceptive and neuropathic pain
• calculate an appropriate starting dose of morphine for opioid-naive patients
• make safe and effective conversions from one opioid to another and from one route of drug administration to another
• prescribe appropriate treatments for common side effects such as nausea and constipation associated with opioid use
• prescribe appropriate nonopioid adjuvant drugs to treat nociceptive and neuropathic pain
  • manage acute and procedural pain 
  • be familiar with nonpharmacologic pain management strategies
  • be familiar with the needs of special populations.

UNIPAC 4 Managing Nonpain Symptoms

• recognize the importance of using symptom assessment tools to ensure comprehensive data col-lection and objective comparison between patient encounters
• emphasize goal-oriented decision making when facilitating family discussions and developing a plan of care
• assess and provide effective interventions for dyspnea, including
  • nonpharmacologic management of dyspnea
  • pharmacologic management of dyspnea
  • management of pulmonary congestion and secretions
  • refractory dyspnea and proportional palliative sedation
  • compassionate ventilator withdrawal
• assess and provide effective interventions for dysphagia, including
  • nonpharmacologic management of dysphagia
  • pharmacologic management of dysphagia
  • surgical interventions for irreversible dysphagia
• assess and provide effective interventions for anorexia-cachexia, including
  • treating reversible causes of anorexia-cachexia
  • pharmacologic management of anorexia-cachexia
  • role of artificial nutrition and hydration
• assess and provide effective interventions for fatigue, including
  • nonpharmacologic management of fatigue
  • pharmacologic management of fatigue
• assess and provide effective interventions for nausea and vomiting, including
  • pathophysiology and etiology of nausea and vomiting
  • nonpharmacologic management of nausea and vomiting
  • pharmacologic management of nausea and vomiting
  • alternative routes of medication deliver

UNIPAC 5 Communication and Teamwork

• use effective strategies when communicating with patients, families, and other healthcare professionals
• use effective techniques when communicating bad news
• use knowledge of family systems theory and counseling techniques to facilitate family conferences
• use knowledge of the roles and functions of team members to interact more effectively as a team member
• use conflict-resolution skills to promote effective teamwork
• use knowledge of basic issues to guide decisions about respecting confidentiality
• use effective techniques to manage the stress associated with caring for patients with terminal illness.

UNIPAC 6 Ethical and Legal Issues

• apply the decision-making process described in this UNIPAC when making ethical decisions
• apply knowledge of medical ethical principles to clinical situations
• differentiate instructive and proxy directives
• provide guidance when obtaining informed consent for care and research in hospice and palliative care settings
  • provide ethical guidance for patients and family members when they
  • express misconceptions about opioids that interfere with optimal pain management
  • make decisions about cardiopulmonary resuscitation
  • make decisions about futile treatment
  • make decisions about the withdrawal of artificial ventilation
  • make decisions about the withdrawal of artificial nutrition and hydration
  • request assisted suicide or euthanasia

UNIPAC 7 Caring for People with HIV/AIDS Ethical

• improve the quality of life of patients with human immunodeficiency virus (HIV) disease
• identify behaviors that increase the risk of HIV disease progression
• assess prognosis
• help patients set realistic goals
• manage selected HIV-specific symptoms
• identify the short- and long-term side effects of antiretroviral therapy
• discuss the withdrawal of antiretroviral therapy
• identify methods for coping with multiple losses
• describe recommendations for caring for HIV patients safely.

UNIPAC 8 Caring for Pediatric Patients

• Define pediatric palliative care (PPC) and related concepts, including patient demographics and hospice eligibility criteria.
• Identify similarities and differences between adult palliative care and PPC.
• Identify barriers to providing comprehensive palliative care for pediatric patients from the time of diagnosis of a life-threatening condition and strategies to circumvent those barriers.
• Use effective communication techniques when discussing palliative care, chronic conditions, terminal illness, and death with children and their families.
• Recognize anticipatory, normal, and pathologic grief and initiate effective interventions to help families through their bereavement.
• Initiate effective management of psychosocial issues, including practical concerns, related to children with life-threatening conditons.
• Identify and explain ethical and legal issues related to palliative care for pediatric patients.
• Assess pain in pediatric patients.
• Manage pain and opioid-related side effects in pediatric patients.
• Assess and manage nonpain symptoms in pediatric patients.
• Assess and manage refractory symptoms in pediatric patients.
• Anticipate and manage the physical, psychosocial, and spiritual suffering surrounding a child's death.

UNIPAC 9 Caring for Patients with Chronic Illnesses: Dementia, COPD, and CHF

Dementia

identify the most common etiologies of dementia and their pathogenesis in the United States

• understand the prevalence of dementia in the United States and its age-related variation
• describe the typical disease course for a person with Alzheimer's dementia
• describe the currently available pharmacologic therapies for the treatment of Alzheimer's disease, including their mechanisms of action, indications, and common side effects
• develop a strategy to assess pain in people with mild-to-moderate and severe-to-end-stage dementia
• list the behavioral and psychological symptoms of dementia (BPSD)
• describe the difference between depression and apathy and understand the unique features of depression in people with dementia, including prevalence, alternative presentations, and treatment options
• list the most commonly used atypical antipsychotics, with dosage recommendations and possible adverse effects
• identify contributing causes to agitation in people with dementia
• recognize frequent complications in patients with end-stage dementia and an approach to their treatment
• review hospice eligibility guidelines for dementia and summarize their limitations
• appreciate the impact of caregiving on people with dementia compared to other life-limiting illnesses.

Chronic Obstructive Pulmonary Disease (COPD)

• List the most common etiologies, prevalence, burden, and mortality of COPD
• describe the disease trajectory for patients with COPD
• describe the neurophysiology of dyspnea
• demonstrate the assessment and treatment of COPD and dyspnea, including pharmacologic approaches, oxygen, opioids, and nonpharmacologic approaches
• discuss the indications for noninvasive ventilation (NIV) for patients with end-stage COPD
• refer appropriate patients with COPD to palliative care and hospice
• communicate effectively with patients about end-of-life (EOL) care options for patients with COPD
• describe the impact of anxiety and depression on patients with COPD
• educate patients and families on home care and self-management of COPD

Congestive Heart Failure (CHF)

• list CHF classifications (New York Heart Association [NYHA] class and American College of Cardiology/American Heart Association [ACC/AHA] staging)
• describe the disease course and illness trajectory in CHF
• discuss when to initiate palliative care for CHF
• list difficulties in predicting prognosis in CHF
• discuss the prognosis for a patient with CHF, including the differences in prognosis and therapies for patients with preserved ejection fraction
• describe medical and invasive therapies for CHF and how they translate to the palliative care setting
• apply strategies for dosing of sedating medications for CHF
• discuss symptom burden in CHF
• describe when it is appropriate to refer patients with CHF to hospice.