Journal of palliative medicine
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Deficiencies in education about end-of-life care are widely recognized, both in the "formal" or structured curriculum, and in the "informal" curriculum (the culture in which students are immersed as they learn medicine). Numerous approaches to addressing these deficiencies have been identified. These approaches include developing palliative care leaders; improving curricula; creating standards and a process for certification of competence; creating and enhancing educational resources for end-of-life education; faculty development; growing palliative care clinical programs as venues for education; textbook revision; and creating palliative care fellowship training opportunities. Current efforts in these areas are reviewed, and barriers to their implementation are highlighted.
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Comparative Study
Future of end-of-life care: the managed care organization perspective.
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Initial voluntary standards for fellowship programs in palliative medicine were developed through a collaborative process involving the directors of fellowship training programs, the American Academy of Hospice and Palliative Medicine (AAHPM), and the American Board of Hospice and Palliative Medicine (ABHPM). These groups worked with a consultant and representatives from the American Board of Medical Specialties (ABMS) and the Accreditation Council for Graduate Medical Education (ACGME) to create a training structure for the programs that will maximize the likelihood for recognition and accreditation of the subspecialty. An accreditation group modeled after an ACGME residency review committee will be formed to review and adopt the standards, then accredit programs voluntarily.
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In 1996 a specialized palliative care unit was opened at the Linköping University Hospital in Sweden and different patterns of referral from different parts of the district soon became apparent. The aim of this study was to investigate the mechanisms underlying these patterns. During the first 6 months, 133 referrals were analyzed. ⋯ Variations in patterns of referral were also observed in the different hospital-based home care teams (HBHC). In our study differences in the three HBHC teams regarding knowledge, skill, and attitudes might be reflected in variations in patterns of referral. The results illustrate the need for further education regarding referral indications, improvements in documentation of reason for referral, improved communication between HBHC teams and the palliative care unit, and improved prognostication at the end of life.
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In recent years a better understanding of the pharmacologic and pharmacokinetic properties of methadone, including equianalgesic ratios has led to its increased use as a second line opioid for the treatment of pain in patients with cancer. Methadone may be an important alternative for those who have side effects related to the use of other opioids because it has no known active metabolites, is well absorbed by oral and rectal routes, and also has the advantage of very low cost. ⋯ Future research should address the use of methadone as a first-line agent in the management of cancer pain, its use in patients with neuropathic pain, and in those who develop rapid tolerance to other opioids. In some patients with cancer the long half-life of methadone offers the advantage of extended dosing intervals to 12 and even 24 hours, further research is also needed in this area.