Journal of palliative medicine
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In 1996 the University of Rochester School of Medicine, Rochester, New York, began a major curricular reform called the Double Helix Curriculum, integrating basic science and clinical training over 4 years of medical school. This transition provided a unique opportunity to develop and implement a fully integrated, comprehensive palliative care curriculum. ⋯ We view this report not as an ideal curriculum to be emulated in its entirety but as a work in progress that may be somewhat unique to our institution. We intend to illustrate a process of incremental curriculum building, and to generate some fresh teaching ideas from which palliative care educators can select depending on their own curricular needs and objectives.
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Palliative sedation is an effective symptom control strategy for patients who suffer from intractable symptoms at the end of life. Evidence suggests that the use of this practice varies considerably. In order to minimize variation in the practice of palliative sedation within our health region, we developed a clinical practice guideline (CPG) for the use of palliative sedation. ⋯ Feedback from the wider group of stakeholders was used to arrive at the final CPG, which subsequently received approval from the local Medical Advisory Board. The process used to develop the CPG served to develop consensus within the local community of palliative care clinicians regarding the practice of palliative sedation. Subsequently, the CPG was used as a tool for educating other health care providers.
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In 1997, the Oregon Death with Dignity Act was enacted, allowing a physician to prescribe a lethal dose of medication for a competent, terminally ill patient who requests one. In 2000, we conducted single, semistructured, in-depth, face-to-face interviews with 35 Oregon physicians who received a request for a lethal prescription. The interviews focused on physicians' perceptions of patients who requested assisted suicide, the reasons for the request, and the reactions of their families. ⋯ Physicians perceived that these patients viewed living as purposeless and too effortful, and that they were ready for death. The requests, which were forceful and persistent, could occur at any point after diagnosis of the terminal illness, and were paralleled by refusal of medical interventions including palliative treatments. Many family members were reluctant to support these requests until they recognized the strength of the preference.
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Despite ongoing technological advances, patients with end-stage renal disease (ESRD) have a mortality rate of approximately 23% per year, and comorbid cardiovascular, cerebrovascular, and peripheral vascular disorders often make life on dialysis an ordeal. This patient population needs an improved approach to symptom assessment and control, as well as advance care planning and high-quality palliative care. Families need support during the lifetime and after the death of their loved ones. ⋯ The RPCI's programs include symptom management protocols, advance care planning, and bereavement services for families and staff. The Initiative is increasing completion of formal advance directives by the patient population, while staff and families are particularly pleased with annual renal memorial services. The RPCI experience has much to offer the practice of nephrology, and it is relevant to ongoing efforts to extend palliative medicine beyond the traditional focus on cancer and AIDS.