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Accepted Manuscript
Development of Entrustable Professional Activities for Hospice and PalliativeMedicine Fellowship Training in the United States
Lindy H. Landzaat, DO FAAHPM, Assistant Professor, Hospice and PalliativeMedicine Fellowship Program Director, Michael D. Barnett, MD MS FAAP FAAHPM,Palliative Medicine Fellowship Program Director, Assistant Professor of Medicine& Pediatrics, Gary T. Buckholz, MD FAAHPM, Associate Clinical Professor, Co-Program Director, Jillian L. Gustin, MD FAAHPM, Clinical Assistant Professor,Hospice and Palliative Medicine Fellowship Program Director, Jennifer M. Hwang,MD MHS, Director of Education, Pediatric Advanced Care Team and Hospice andPalliative Medicine Fellowship Director, Assistant Professor of Clinical Pediatrics,Stacie K. Levine, MD FAAHPM, Associate Professor, Hospice and Palliative MedicineFellowship Program Director, Director of Palliative Medicine Programs, Tomasz Okon,MD, Director, Marshfield Clinic Palliative Medicine Fellowship, Steven M. Radwany,MD FACP FAAHPM, Hospice and Palliative Medicine Fellowship Director, Holly B.Yang, MD MSHPEd HMDC FAAHPM FACP, Assistant Clinical Professor, Hospiceand Palliative Medicine Fellowship Program Co-Director, John Encandela, PhD,Associate Professor of Psychiatry, Associate Director for Curriculum and EducatorAssessment, Laura J. Morrison, MD FAAHPM, Hospice and Palliative MedicineFellowship Program Director, Associate Professor of Medicine
PII: S0885-3924(17)30266-X
DOI: 10.1016/j.jpainsymman.2017.07.003
Reference: JPS 9428
To appear in: Journal of Pain and Symptom Management
Received Date: 27 January 2017
Revised Date: 6 June 2017
Accepted Date: 6 July 2017
Please cite this article as: Landzaat LH, Barnett MD, Buckholz GT, Gustin JL, Hwang JM, Levine SK,Okon T, Radwany SM, Yang HB, Encandela J, Morrison LJ, Development of Entrustable ProfessionalActivities for Hospice and Palliative Medicine Fellowship Training in the United States, Journal of Painand Symptom Management (2017), doi: 10.1016/j.jpainsymman.2017.07.003.
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service toour customers we are providing this early version of the manuscript. The manuscript will undergocopyediting, typesetting, and review of the resulting proof before it is published in its final form. Pleasenote that during the production process errors may be discovered which could affect the content, and alllegal disclaimers that apply to the journal pertain.
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Development of Entrustable Professional Activities for Hospice and Palliative Medicine Fellowship Training in the United States
Lindy H. Landzaat, DO FAAHPM, Assistant Professor, Hospice and Palliative Medicine Fellowship Program
Director, Department of Internal Medicine, University of Kansas Medical Center, Kansas City, KS, USA
Michael D. Barnett, MD MS FAAP FAAHPM, Palliative Medicine Fellowship Program Director, Assistant
Professor of Medicine & Pediatrics, University of Alabama at Birmingham, Birmingham, AL, USA
Gary T. Buckholz, MD FAAHPM, Associate Clinical Professor, Co-Program Director University of California San
Diego/Scripps Health Hospice and Palliative Medicine Fellowship, University of California San Diego, La
Jolla, CA, USA
Jillian L. Gustin, MD FAAHPM, Clinical Assistant Professor, Division of Palliative Medicine, Department of
Internal Medicine, Hospice and Palliative Medicine Fellowship Program Director, The Ohio State
University Wexner Medical Center, Columbus, OH, USA
Jennifer M. Hwang, MD MHS, Director of Education, Pediatric Advanced Care Team and Hospice and Palliative
Medicine Fellowship Director, The Children's Hospital of Philadelphia. Assistant Professor of Clinical
Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
Stacie K. Levine, MD FAAHPM, Associate Professor, Hospice and Palliative Medicine Fellowship Program
Director, Director of Palliative Medicine Programs, University of Chicago, Chicago, IL, USA.
Tomasz Okon, MD, Director, Marshfield Clinic Palliative Medicine Fellowship Marshfield Clinic, Marshfield, WI,
USA
Steven M. Radwany, MD FACP FAAHPM, Hospice and Palliative Medicine Fellowship Director, Ethics
Committee Chair, Summa Health / Northeast Ohio Medical University, Akron, OH, USA.
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Holly B. Yang, MD MSHPEd HMDC FAAHPM FACP, Assistant Clinical Professor, University of California San
Diego/Scripps Health Hospice and Palliative Medicine Fellowship Program Co-Director, Scripps Health
San Diego, CA, USA
John Encandela, PhD, Associate Professor of Psychiatry, Associate Director for Curriculum and Educator
Assessment, Teaching & Learning Center Yale School of Medicine, Yale School of Medicine, New
Haven, CT, USA
Laura J. Morrison, MD FAAHPM, Hospice and Palliative Medicine Fellowship Program Director, Yale Palliative
Care Program, Associate Professor of Medicine, Department of Medicine, Yale School of Medicine,
New Haven, CT, USA
Running Title: HPM Entrustable Professional Activities
Corresponding author contact information:
Lindy Landzaat DO FAAHPM,
3901 Rainbow Blvd, MS 1020, University of Kansas Medical Center, Kansas City, KS, 66160 USA
Phone: 913-588-3807 fax: 913-588-3877 email: [email protected]
Abbreviations used:
EPAs Entrustable Professional Activities
AAHPM American Academy of Hospice and Palliative Medicine
HPM Hospice and Palliative Medicine
ACGME Accreditation Council for Graduate Medical Education
NAS Next Accreditation System
CM Curricular Milestone
CMs Curricular Milestones
US United States
HMD Hospice Medical Director
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FAQ Frequently Asked Question
ABMS American Board of Medical Specialties
IDT Interdisciplinary team
LST Life Sustaining Therapies
Figures in paper do not require color.
Keywords: Entrustable Professional Activities, Hospice, Palliative Care, Fellowship, Graduate Medical
Education
Author Contribution List
Lindy H. Landzaat: Lead manuscript author and primary EPA author; associate chair of workgroup with
significant input to overall project design and methods, primary data analysis and interpretation
Michael D. Barnett: Primary EPA author and critically revised manuscript for important intellectual content;
workgroup member; contributed to project design and methods, data analysis & interpretation
Gary T. Buckholz: Primary EPA author and critically revised manuscript for important intellectual content;
workgroup member; contributed to project design and methods, data analysis & interpretation
Jillian L. Gustin: Primary EPA author and critically revised manuscript for important intellectual content;
workgroup member; contributed to project design and methods, data analysis & interpretation
Jennifer M. Hwang: Primary EPA author and critically revised manuscript for important intellectual content;
workgroup member; contributed to project design and methods, data analysis & interpretation
Stacie K. Levine: Primary EPA author and critically revised manuscript for important intellectual content;
workgroup member; contributed to project design and methods, data analysis & interpretation
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Tomasz Okon: Primary EPA author and critically revised manuscript for important intellectual content;
workgroup member; contributed to project design and methods, data analysis & interpretation
Steven “Skip” Radwany: Primary EPA author and critically revised manuscript for important intellectual
content; workgroup member; contributed to project design and methods, data analysis & interpretation
Holly B. Yang: Primary EPA author and critically revised manuscript for important intellectual content;
workgroup member; contributed to project design and methods, data analysis & interpretation
John Encandela: Provided significant manuscript revisions; contributed to national survey design; performed
data analysis, statistical support and interpretation.
Laura J. Morrison: Senior author providing significant manuscript revisions and primary EPA author; chair of
workgroup and responsible for overall project design and methods, primary data analysis and interpretation.
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Development of Entrustable Professional Activities for Hospice and Palliative Medicine Fellowship Training in the United States
Landzaat LH, Barnett MD, Buckholz GT, Gustin JL, Hwang JM, Levine SK, Okon T, Radwany SM, Yang
HB, Encandela J, Morrison LJ
Context: Entrustable Professional Activities (EPAs) represent the key physician tasks of a specialty. Once a
trainee demonstrates competence in an activity, they can then be ‘entrusted’ to practice without supervision1.
A physician workgroup of the American Academy of Hospice and Palliative Medicine (AAHPM) sought to define
Hospice and Palliative Medicine (HPM) EPAs.
Objective: To describe the development of a set of consensus EPAs for HPM fellowship training in the United
States.
Methods: A set of HPM EPAs was developed through an iterative consensus process involving an expert
workgroup, vetting at a national meeting with HPM educators, and an electronic survey from a national
registry of 3,550 HPM physicians. Vetting feedback was reviewed and survey data were statistically analyzed.
Final EPA revisions followed from the multisource feedback.
Results: Through the iterative consensus process, a set of 17 HPM EPAs was created, detailed, and revised. In
the national survey, 362 HPM specialists responded (10%), including 58 of 126 fellowship program directors
(46%). Respondents indicated the set of 17 EPAs well-represented the core activities of HPM physician
practice (mean 4.72 on a 5-point Likert scale) and considered all EPAs to either be “essential” or “important”
with none of the EPAs ranking “neither essential, nor important.”
Conclusions: A set of 17 EPAs was developed using national input of practicing physicians & program directors
and an iterative expert workgroup consensus process. The workgroup anticipates EPAs can assist fellowship
directors with strengthening competency-based training curricula.
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Introduction:
The transition from the Accreditation Council for Graduate Medical Education’s (ACGME) 1999 Outcome
Project to the 2013 Next Accreditation System (NAS) has evoked new challenges in graduate medical training
as programs continue to adapt and evolve from process-related compliance to demonstration of meaningful
competency-based outcomes in resident education.2,3
Entrustable Professional Activities (EPAs) emerged
independent of, and complementary to, the new NAS framework. They define the “essential tasks of
professional practice.”4 EPAs are observable, meaningful, manageable points of assessment that characterize a
physician’s key activities within a medical specialty5. These representative activities are “entrusted” to the
trainee, to perform without supervision, once they gain and demonstrate competence.1,6
Each EPA requires a
combination of knowledge, skills, and attitudes to execute, and draws on multiple ACGME core competencies
for successful entrustment. Some medical disciplines in the US have defined specialty-specific EPAs.7,8,9,10
Additionally, the Canadian Society of Palliative Care Physicians released a set of Palliative Medicine EPAs in
2015.11
HPM EPAs serve several valuable roles as they describe the essential work of the field for medical providers,
educators, and the larger healthcare community6. First, by defining core HPM physician activities, EPAs aid in
educating the wider community about the evolving role of HPM. This is particularly helpful since HPM fellows
in the US may seek fellowship training after completing one of 11 different residency backgrounds.
Additionally, as alternative mid-career training pathways develop to help address HPM workforce shortages12
,
EPAs can pave the way for innovative delivery of curricula with comparable core content. The hope is that
EPAs will directly and positively influence fellowship training and ultimately improve patient and family care
outcomes.
The American Academy of Hospice and Palliative Medicine (AAHPM) has a long history of sponsoring
workgroups to promote development of Hospice and Palliative Medicine (HPM) medical education.
Workgroups have created adult and pediatric focused HPM competencies, measurable outcomes, and a toolkit
of assessment methods to support fellowship training. 13,14,15,16,17
In response to the NAS charge to better
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define competency-based outcomes, AAHPM convened a 2014 workgroup of expert HPM educators charged
with defining EPAs for HPM fellowship training, the EPA Workgroup (hereafter, “the workgroup”). This paper
describes the workgroup’s process for developing the 17 HPM EPAs for US fellowship trainees.
Methods:
EPA Development:
To develop EPAs, a workgroup undertook a group vetting and consensus process that drew elements from
modified Delphi and Nominal Group Processes18
. The workgroup included ten physician members
representing diversity in adult and pediatric care, geography, gender, years of practice, and hospice and
academic practice settings. All members served as HPM fellowship directors and led multiple HPM educational
initiatives at their institutions.
At an in-person inaugural meeting in May 2014, the workgroup benchmarked with other specialty and
subspecialty EPAs and consulted with ACGME Milestone Development leadership to define the aims and
processes for HPM EPA development. The workgroup defined HPM EPAs as the critical tasks expected of a
fellow by the end of training. Throughout the EPA development path, the workgroup regularly referenced the
EPA characteristics 6,9 originally defined by ten Cate. The workgroup recognized that while an HPM graduating
fellow may not ultimately perform all the EPAs in future independent practice, the EPA set should include
important activities that prepare graduating fellows for the diverse work of HPM. The workgroup favored a set
of EPAs that was observable and limited in number, yet inclusive enough to meaningfully represent the
essential work of an HPM physician.
After developing a common understanding of EPAs, the workgroup initially identified eighteen EPA topics.
Working in 5 dyads that each drafted 3 or 4 EPAs, the workgroup created the first set of 18 EPAs. From May
2014 to October 2015, the workgroup conducted twenty 90-minute meetings: nineteen conference calls and
another in-person session at the 2015 national AAHPM conference. Through an iterative process, (see Figure
1), each workgroup member fully reviewed each individual EPA for content as well as fit in the set at least
twice. The set was reviewed multiple times as a whole to assess the need to combine, split, or add EPAs. In
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addition to reviewing, workgroup members also revised assigned EPAs with group discussion for consensus.
After two rounds of review and revision, 16 EPAs remained from the initial list of 18.
EPA vetting process:
The workgroup pursued a multiphase external vetting process to ensure the EPA set was comprehensive and
to garner consensus within the HPM community. First, the workgroup invited a convenience sample of
twenty recent fellowship graduates to review a preliminary set of EPAs for any omissions in light of the
everyday tasks defining their current professional roles. Fifteen provided feedback that was examined by the
workgroup and resulted in no EPA additions. Next, at the February 2015 AAHPM Annual Assembly, over 100
HPM physician fellowship leaders (the majority being fellowship program directors) each participated in a two-
and-a-half hours EPA vetting session, including a didactic presentation of background content and process
information, a facilitated small group exercise to review and provide specific feedback on four assigned EPAs,
and a large group debriefing to identify additional feedback. Additionally, a subsequent one-hour session at
the same Assembly, open to all interprofessional conference attendees, garnered feedback from 74 registrants
in a similar but abbreviated process. The workgroup performed a detailed review of the comments as part of
the ongoing iterative process (Figure 2). Some feedback suggested changes for content felt to be more
relevant at a learning objective or curricular milestone level, rather than an EPA level. Other times, the
content was already included as part of the more detailed EPA set though that may not have been readily
apparent to the participant. Three significant outcomes resulted: the creation of a new 17th EPA, targeted
revisions to the EPA set, or the addition of text in the final document describing the workgroup’s rationale for
content decisions.
National Survey Vetting:
The final vetting activity was an electronic survey distributed to the AAHPM physician membership (3,550
physician members listed in the national registry) with the goal of achieving a robust, broad measure of
consensus across the field on how well the EPAs represented the essential activities of practicing HPM
physicians. A 3-week time window for completion was provided.
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After offering a brief context and description of Entrustable Professional Activities, participants were asked to
reflect on the core tasks that define their role as an HPM physician and then, to rate, using a 5-point Likert
Scale (“very poorly” to “very well”) how well the EPA-set represented core tasks of HPM practice. Participants
were also asked to review each proposed EPA for “how essential or important is competence in each proposed
EPA” for a graduating HPM fellow. Modeled off similar surveys,19,20
options included “Essential for all”,
“Important for all but not essential”, or “Not important or essential.” The survey also solicited potential EPA
omissions and collected demographic information on the participants (Table 1). This study received exempt
status by both the Yale University Human Investigation Committee and the University of Kansas Human
Subjects Committee.
Statistical Analysis:
To analyze how well the EPAs represented the core tasks of HPM practice, means and frequencies for each of
the EPAs were established. Percentages of respondents’ priority ratings (i.e., essential, important but not
essential, and not important or essential) were also established for each EPA. Chi square tests were performed
for each of 19 independent variables (e.g., respondent gender, age, role vis-à-vis HPM practice and teaching,
years in practice, etc.) as these were associated with respondent perceptions of priority rating for each EPA.
Only those associations found to be significant are reported below in the Results section, with explanations of
how these findings informed our decisions about EPAs. Frequencies and percentages were also established to
describe respondent demographics and characteristics of their work.
Results:
EPA Development:
During the iterative process of review and revision, the initial draft of 18 EPA topics transitioned to 16 EPAs.
Five EPA topics merged into one, 3 new topics emerged, and one was topic was eliminated. In direct response
to vetting comments from the two national conference sessions, a new EPA, “Promote and teach hospice and
palliative care,” was added, resulting in a final total of 17 EPAs (Appendix 1). In the end, each of the 17 EPAs
included a title, an expanded description, and relevant, bulleted knowledge, skills, and attitudes. A summary
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of feedback and resulting actions is included in Figure 2. The workgroup created a Frequently Asked
Questions section of the EPA document to address some of the recurring feedback obtained during the vetting
process. The final EPA list was released to the field on November 23, 2015 with an online document21
.
National Vetting Survey:
A total of 362 physicians participated out of 3550 potential participants, yielding a 10% response rate.
Participant demographics are listed in Table 1. Respondents generally dedicated over 75% of their time to
practice of HPM, 41% served as hospice medical director or hospice team physician, and approximately 90%
were involved in teaching medical trainees. Nearly three times as many respondents practiced primarily in
palliative care settings as in hospice settings (58.9% vs. 20.4%). Fifty-eight respondents were HPM Fellowship
Directors representing approximately 46% of the 126 HPM fellowship program directors.
The mean rating of how well the set of 17 EPAs represent the core activities for HPM physicians using a 5-point
Likert scale was 4.72 (SD=0.65). As noted in Table 2 and Figure 3, none of the 17 EPAs fell into the primary
category of “not essential or important.” With EPAs being a new concept in HPM, there is no accepted level of
consensus to guide inclusion or exclusion. The workgroup anticipated that any EPAs rating primarily as “not
essential, nor important” would have been eliminated and those with a majority vote of “essential” would
likely be retained.
All but one of the EPAs fell primarily into the “essential” category. EPA 15, “Fulfill the role of a hospice medical
director,” had a majority of responses in the “important but not essential for all” category. Chi square results
showed, not surprisingly, that hospice medical directors, also referred to as hospice team physicians, (41% of
respondents) were statistically more likely to rate this EPA higher than colleagues not working in hospice (p
<0.01). The majority of respondents, however, (59%) practiced palliative care but not hospice. The workgroup
reviewed all survey data in detail, including all comments, elected to retain all 17 EPAs, and made final
revisions.
Discussion
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This paper reports the development of 17 consensus HPM EPAs that expand the national education
infrastructure for HPM fellowship training. This defined list of key physician activities is expected to serve as a
guide to inform HPM Fellowship curricula and may serve as the basis for designing performance assessment
tools to determine fellow physician entrustment. EPAs may prompt fellowship programs to examine their
current curricula and highlight a need for focused attention on competence in key clinical tasks. Because they
are not a current requirement, fellowship programs have flexibility in which EPAs to use and how to use them.
The EPAs also provide fellows a more specific framing of the entrustment tasks expected of them by the end of
fellowship, including detailing of the requisite knowledge, skills, and attitudes for each.
Strengths of our process included an extensive iterative process by a workgroup of expert HPM educators,
vetting at a national meeting with program directors and practicing providers, and vetting through a national
survey of HPM physicians. Our survey participants were clinically active, represented both hospice and
palliative care settings, and were routinely involved in HPM education.
The EPA development process and vetting included limitations. First, regarding the survey design, the
measurement of reliability for survey takers is limited given the single administration design. The survey
response rate was relatively low at 10%. The workgroup opted to err on the side of broader representation
and ‘cast the net widely’ by sending the survey invitation to all AAHPM physician members. The 10% response
rate is in line with the average for a convenience sample on AAHPM surveys22. Program directors were
represented with 46% participating, a response rate in line with a similar national educational workgroup
vetting process20
. The threat of bias that exists with convenience sampling may be offset somewhat in our
study by the fact that two important constituencies—hospice medical directors/team physicians and
fellowship directors—were relatively well represented in the sample.
Our process highlights a number of ongoing challenges for competency-based education and others pursuing
EPA development. One challenge was how to effectively balance breadth and depth of EPAs in light of the
need for practical application. The workgroup aimed to define EPAs that were discrete enough to be
observable and potentially measurable while keeping the total number manageable for one-year HPM clinical
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fellowships. Another challenge was finding the balance between “lumping and splitting” different EPAs. For
instance, should the Psychosocial EPA #11, and Spiritual Care EPA #12 be merged into a broader Support EPA
or remain distinct? Should EPA #6, ‘Participate as a member or leader of an interdisciplinary team,’ be its own
EPA or simply be an element included within multiple EPAs? The workgroup chose to elevate particular
constructs to individual EPAs in order to underscore the importance of certain sets of knowledge and skills
necessary to perform the work as part of the field’s current growth and professional expectation. The
workgroup chose to address some of the areas that generated a lot of discussion by offering rationales in a
Frequently Asked Question (FAQ) section within the final EPA document21
. EPAs are a new framework
currently not required by the ACGME and may be unfamiliar to many educators. Therefore, how EPAs will be
applied is unclear, complicating our goal of designing them to be useful and practical. Finally, as originally
defined, EPAs are to be independently executable.6 This is important to successful evaluation of an individual’s
performance, but for an inherently team-based specialty, “independently executable6” may prove a practical
implementation challenge.
Our vetting process also suggested that variability exists within the HPM field in the interpretation of “Hospice
Medical Director” terminology (EPA #15). The title may broadly refer to any physician employed by a hospice
(i.e. a hospice team physician). In some settings, however, this title is reserved for a single lead physician of a
hospice organization. The workgroup intended the former definition for EPA #15. However, ambiguity around
the term could have confounded and lowered the ratings for this EPA if respondents considered the narrower
HMD definition. In addition, very few survey participants thought this EPA warranted the lowest category of
'not important or essential'. There was universal workgroup consensus that this EPA was in fact 'essential to
all.' In considering the risk of burden to harm, since EPAs are not an ACGME requirement and program
directors have discretion about which EPAs they use and how they use them, keeping a potentially less useful
EPA in the set seemed to be a safer approach than discarding a potentially ‘essential-to-training’ EPA. Given
that, the workgroup elected to retain EPA #15 as part of the final EPA set. Since field-specific terminology can
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be interpreted inconsistently and complicate the vetting process, the workgroup suggests that others
proactively anticipate and address terminology dilemmas if vetting EPAs.
Conclusion: The AAHPM EPA workgroup developed a consensus set of 17 EPAs that represent the essential
activities of entrustment for US HPM fellowship graduates. The set of 17 EPAs rated highly as representing the
core activities of HPM after a multi-phased vetting process. This final EPA list describes key HPM physician
tasks and defines EPAs for the field of HPM. It offers fellowship programs a tool to assist with competency-
based curricula and a launching point for developing entrustment assessments. The practical application and
experience of applying the new EPA construct to HPM fellowship training, mid-career training pathways, and
other settings will inform future research, revisions, and future iterations of HPM EPAs.
Disclosures & Acknowledgments: This work received administrative support and travel-related funding for
the workgroup’s initial in-person meeting from the Academy of Hospice and Palliative Medicine. There was no
other additional funding for this work. The authors would like to thank the American Academy of Hospice and
Palliative Medicine for supporting HPM EPA development, and specifically thanks Ms. Margaret Rudnik and
Ms. Dawn Levreau for their administrative expertise and contributions to the project. In addition, the
workgroup is appreciative of advising by Laura Edgar, EdD, CAE, ACGME Executive Director for Milestone
Development. The authors declare no conflict of interest.
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Table 1 : National Survey Participant Demographics, n=362
Age (355)
20-29 0.3% 1
30-39 18.0% 64
40-49 26.2% 93
50-59 29.0% 103
60-69 23.4% 83
70 and older 2.5% 9
Prefer not to answer 0.6% 2
Gender (352)
Female 54.0% 190
Male 45.7% 161
Prefer not to answer 0.3% 1
Years in Practice (355)
0-5 25.6% 91
6-10 28.2% 100
11-15 19.4% 69
16-20 10.1% 36
More than 20 16.6% 59
ABMS certified in HPM (354)
Yes 91.8% 325
No 8.2% 29
Hospice medical director/hospice team physician leader (355)
Yes 41.1% 146
No 58.9% 209
Setting(s) where majority of professional time spent (358)
Hospice 20.4% 68
Palliative Care 58.9% 196
Both Hospice and Palliative Care
(close to evenly split) 20.7% 69
Other 7.0% 25
Practice setting (354)
Academic medical center 42.9% 152
Community hospital 19.8% 70
Outpatient clinic 3.1% 11
Hospice 20.9% 74
Other 13.3% 47
Hours per week devoted to HPM (355)
<25 % 10.4% 37
25-50% 13.5% 48
51-75% 9.6% 34
>75% 66.5% 236
Teaching Responsibilities (355)
Involved in teaching medical trainees 89.6% 318
Not teaching medical trainees 10.4% 37
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Table 2: Vetting Survey to AAHPM physician members with EPA rankings
How essential or important is competence in each proposed EPA for a graduating HPM fellow?
# EPA Description
N=362
%
Essential
to all
% Important
but not
essential
% Not
important or
essential
1 Provide comprehensive pain assessment and management
for patients with serious illness. HPM physicians are able
to use an interdisciplinary team approach to effectively
manage complex pain in the context of serious illness using
pharmacologic and non-pharmacologic approaches.
99.2 0.8 0
2 Provide comprehensive non-pain symptom assessment
and management for patients with serious illness. HPM
physicians are able to lead and collaborate with an
interdisciplinary team to effectively manage complex non-
pain symptoms, including but not limited to anorexia,
constipation and diarrhea, delirium, dyspnea, fatigue,
nausea and vomiting, depression and anxiety, using
pharmacologic and non-pharmacologic treatments.
98.1 1.9 0
3 Manage palliative care emergencies. HPM physicians
anticipate, prepare for, and respond to palliative
emergencies to minimize distress in partnership with the
patient, caregivers, and medical team, while taking into
account the patient’s goals of care and prognosis.
89.0 10.8 0.3
4 Estimate and communicate prognosis to aid medical
decision-making. HPM physicians are able to estimate,
communicate, and consider prognosis while acknowledging
uncertainty as they facilitate shared decision-making and
delineate goals of care based on patient/family values.
93.9 5.8 0.3
5 Establish goals of care based on patient/family values and
specific medical circumstancesa. HPM physicians are able
to elicit patient/family values, delineate goals of care based
on patient/family values in the context of the patient’s
medical condition, and make recommendations for an
appropriate care plan.
96.7 2.5 0.8
6 Participate as a member or leader of an interdisciplinary
team. HPM physicians function effectively as a
leader/member of an interdisciplinary team (IDT), manage
patient and family care provided by an IDT, and facilitate
IDT meetings, while sharing the leadership role with other
IDT members as appropriate.
86.2 13.3 0.6
7 Prevent and mediate conflict and distress over complex
medical decisions. HPM physicians prevent and address
clinical conflict and uncertainty as well as emotionally
charged encounters and value laden suffering through
advanced palliative communication techniques.
82.0 17.7 0.3
8 Manage withdrawal of advanced life sustaining therapies.
HPM physicians are skilled in the withdrawal of advanced
life sustaining therapies including facilitation of goals of
care discussions leading to the decision to withdraw
advanced LST, management of symptoms pre- and post-
withdrawal of advanced LST, orchestration of withdrawal of
LST, and provision of family support for psychosocial and
83.7 15.7 0.6
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spiritual distress including anticipatory grief and
bereavement.
9 Care for the imminently dying patient and their family.
HPM physicians are able to identify signs of the dying
process and tend to the needs of the multiple areas of
suffering for an individual patient and their family during
imminent dying and facilitate after death bereavement
support for the family and health care providers.
94.5 5.2 0.3
10 Manage requests for hastened deathb. HPM physicians
manage requests for hastened death in accordance with
federal, state and local regulations as well as ethical and
professional principles while remaining sensitive to
patients’ individual values, preferences and sources of
suffering.
74.0 22.9 3.0
11 Support patient and family in the psychosocial domain.
HPM physicians address patient and family suffering,
coping, and healing in the emotional, psychological and
social domains with focused and developmentally
appropriate assessment followed by targeted
communication, interventions and referrals.
67.4 31.5 1.1
12 Support patient and family in the spiritual and existential
domain. HPM physicians address patient and family
suffering and identify strengths and needs within the
spiritual and existential domain with basic assessment
followed by identification of appropriate interventions and
referrals.
55.0 43.1 1.9
13 Promote self-care and resilience. HPM physicians value
and promote resilience and personal well-being for
themselves and others as a necessary element for
professional success and sustainability.
78.2 20.7 1.1
14 Facilitate transitions across the HPM continuum of care.
HPM physicians are adept at caring for patients and families
across the healthcare continuum (inpatient, long-term care,
ambulatory, home) with an understanding of and
appreciation for resource availability, care coordination,
and transitions support required for effective, high-quality
care.
75.1 24.3 0.6
15 Fulfill the role of a hospice medical director. HPM
physicians meet the clinical, regulatory, administrative and
supportive responsibilities of a hospice medical director.
30.1 63.0 6.9
16 Provide hospice and palliative medicine consultation and
team support. HPM physicians render patient and family
centered consultative care in a professional, timely, and
effective manner which supports and educates the
referring and invested team members.
83.4 15.5 1.1
17 Advocate for and teach palliative carec. HPM physicians
advocate for access to high quality palliative care services
across the continuum of care and enhance other healthcare
providers’ primary palliative care skills and knowledge.
55.5 43.4 1.1
a
Final Version included title change to “Establish goals of care based on patient and/or family values and specific medical
circumstances” b Final Version included title change to “Address requests for hastened death”
c Final Version included title change to “Promote and teach palliative care”
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Figure 1: HPM EPA Step-Wise Development Process
1. Benchmark with other specialties' EPAs
2. Compose initial list of 18 HPM EPAs
3. Author-dyads draft full EPAs including: title, description, required knowledge, skills, attitudes
4. Workgroup members review each EPA individually; provide written feedback to authors
5. Authors review written feedback, discuss revisions on conference calls, seek consensus
6. Repeat steps 4 & 5 for second round review of all EPAs
7. Input from 15 Recent Fellow Graduates
8. Vetting at AAHPM national meeting – approx. 174 fellowship leaders and HPM educators
9. Addition of EPA #17
10. Vetting with national survey to field-362 respondents
11. Iterative review of national survey feedback, revisions
12. Final 17 HPM EPAs released
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Figure 2 : Workgroup Review Process for Multisource Feedback by Comment Topic
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0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Figure 3 : Respondent Ratings of 17 Preliminary EPAs
n=362
Essential to all Important but not essential Not important or essential
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Appendix 1 (option A)
Final List of HPM Entrustable Professional Activities
1 Provide comprehensive pain assessment and management for patients with serious illness
2 Provide comprehensive nonpain symptom assessment and management for patients with serious
illness
3 Manage palliative care emergencies
4 Estimate and communicate prognosis to aid medical decision-making
5 Establish goals of care based on patient and/or family values and specific medical circumstances
6 Participate as a member or leader of an interdisciplinary team
7 Prevent and mediate conflict and distress over complex medical decisions
8 Manage withdrawal of advanced life-sustaining therapies
9 Care for imminently dying patients and their families
10 Address requests for hastened death
11 Support patients and families in the psychosocial domain
12 Support patients and families in the spiritual and existential domain
13 Promote self-care and resilience
14 Facilitate transitions across the HPM continuum of care
15 Fulfill the role of a hospice medical director
16 Provide HPM consultation and team support
17 Promote and teach hospice and palliative care
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Appendix 1 (option B)-[these are the full 17 EPAs if the journal chooses to include and pending discussions
with AAHPM related to copyright]
Hospice & Palliative Medicine EHospice & Palliative Medicine EHospice & Palliative Medicine EHospice & Palliative Medicine EPA Title: EPA 1. Provide comprehensive pain assessment and PA Title: EPA 1. Provide comprehensive pain assessment and PA Title: EPA 1. Provide comprehensive pain assessment and PA Title: EPA 1. Provide comprehensive pain assessment and
management for patients with serious illness.management for patients with serious illness.management for patients with serious illness.management for patients with serious illness.
Detailed Description: HPM physicians lead and collaborate with an interdisciplinary team (IDT) approach to effectively
manage complex pain in the context of serious illness using pharmacologic and nonpharmacologic approaches.
List specific
Knowledge
• Explain the pathophysiology of pain across the age spectrum, from pediatrics to
geriatrics.
• List components of a detailed pain assessment, including developmentally
appropriate screening and assessment tools.
• Explain the domains of whole-patient assessment and their potential impact on
reported physical pain (total pain).
• Describe the pharmacokinetics, pharmacodynamics, and potential adverse effects of
opioids and nonopioid pain medications to achieve proportionate symptom control.
• Describe safe opioid-prescribing practices such as use of the Opioid Risk Tool (ORT),
pain contracts, appropriate storage and disposal, risk evaluation and mitigation
strategies (REMS), state and local regulations, and aberrant behaviors associated with
misuse.
• List nonpharmacologic approaches to manage pain.
• List procedural approaches (along with referral services) to manage pain.
• Describe relative costs of medications and other therapies to treat pain.
Skills
• Perform a comprehensive pain assessment, including all domains of suffering.
• Collaborate with the IDT and other providers to optimally manage pain.
• Utilize appropriate diagnostic workup and interpretation of diagnostic tests.
• Develop and implement plans to provide comprehensive pain management for the
full spectrum of pain syndromes.
• Recognize and manage adverse effects of medications and other therapies.
• Communicate treatment plans clearly to individual patients, their families, and
healthcare providers.
• Implement safe opioid-prescribing practices.
• Demonstrate cost-effective care.
Attitudes
• Appreciate the important, urgent nature of pain management.
• Recognize the necessity of managing physical suffering to allow patients to better
address other domains of suffering and improve quality of life.
• Appreciate the complex interplay between physical and other domains of suffering
and the role of the IDT
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Hospice & Palliative Medicine EPA Title: EPA 2. Provide comprehHospice & Palliative Medicine EPA Title: EPA 2. Provide comprehHospice & Palliative Medicine EPA Title: EPA 2. Provide comprehHospice & Palliative Medicine EPA Title: EPA 2. Provide comprehensive nonpain symptom ensive nonpain symptom ensive nonpain symptom ensive nonpain symptom
assessment and management for patients with serious illness.assessment and management for patients with serious illness.assessment and management for patients with serious illness.assessment and management for patients with serious illness.
Detailed Description: HPM physicians lead and collaborate with an interdisciplinary team (IDT) to effectively manage
complex nonpain symptoms, including but not limited to anorexia, constipation and diarrhea, delirium, dyspnea,
fatigue, nausea and vomiting, depression, and anxiety using pharmacologic and nonpharmacologic treatments.
List specific
Knowledge
• Describe the pathophysiology of common symptoms in serious illness across the age
spectrum, from pediatrics to geriatrics.
• Describe diagnostic methods necessary for optimal symptom assessment.
• List developmentally appropriate nonpain symptom screening and assessment tools.
• Identify pharmacologic and nonpharmacologic treatments for nonpain symptoms
using the current evidence base in palliative medicine.
• Recognize the expected benefits, burdens, and relative costs of various treatment
modalities and medications.
Skills
• Perform a thoughtful, comprehensive, and systematic symptom assessment using
validated scales or tools when appropriate.
• Demonstrate appropriate diagnostic workup and interpretation of test results.
• Use evidence-based nonpharmacologic and pharmacologic therapies and adjust
treatment plan based on results and side effects.
• Make appropriate referrals to other specialists and members of the IDT to assist with
symptom management.
• Communicate treatment plans clearly to patients, families, and healthcare providers.
• Demonstrate cost-effective care.
Attitudes
• Appreciate the important, urgent nature of nonpain symptom management.
• Recognize the value of input from multiple disciplines in addressing challenging
nonpain symptoms.
• Appreciate the importance of symptom management in diminishing suffering and
improving quality of life.
• Maintain a supportive presence for the suffering that comes with intractable
symptoms
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Hospice & Palliative Medicine EPA Title: EPA 3. Manage palliative care emergencies.Hospice & Palliative Medicine EPA Title: EPA 3. Manage palliative care emergencies.Hospice & Palliative Medicine EPA Title: EPA 3. Manage palliative care emergencies.Hospice & Palliative Medicine EPA Title: EPA 3. Manage palliative care emergencies.
Detailed description: HPM physicians anticipate, prepare for, and respond to palliative care emergencies in partnership
with the patient, caregivers, and medical team while taking into account the patient’s goals of care and prognosis.
List specific
Knowledge
• Define and list palliative care emergencies characterized by a high symptom burden
and decreased quality of life. These may include medical, surgical, psychiatric, and
iatrogenic emergencies as well as severe psychosocial crises for patients and/or
families/caregivers.
• Describe the risk factors and pathophysiology of specific palliative care emergencies.
• Identify various modalities to decrease symptom burden and/or modify underlying
pathology that can be implemented in each emergency.
Skills
• Anticipate, recognize, and proactively consider risk mitigation strategies for all
categories of palliative care emergencies.
• Use an interdisciplinary approach to identify, prepare for, and provide
comprehensive management of palliative care emergencies.
• Demonstrate judicious and rapid escalation of palliative therapies proportional to the
degree of distress and suffering.
• Provide support to patients and/or families including prognostication and
reassessment of goals of care before, during, and after a palliative care emergency.
• Demonstrate a supportive presence for patients, caregivers, and staff, especially
when managing an “unfixable” emergency.
Attitudes
• Embrace the responsibility of identifying palliative care emergencies and
expeditiously acting on them.
• Appreciate the emotional impact of preparing for, witnessing, and managing
emergencies for patients, families, medical teams, and palliative care providers.
• Recognize that competent management of palliative care emergencies decreases
suffering and may improve quality of life.
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Hospice & PalliativeHospice & PalliativeHospice & PalliativeHospice & Palliative Medicine EPA Title: EPA 4. Estimate and communicate prognosis to aid Medicine EPA Title: EPA 4. Estimate and communicate prognosis to aid Medicine EPA Title: EPA 4. Estimate and communicate prognosis to aid Medicine EPA Title: EPA 4. Estimate and communicate prognosis to aid
medical decisionmedical decisionmedical decisionmedical decision----making.making.making.making.
Detailed Description: HPM physicians estimate, communicate, and consider prognosis while acknowledging
uncertainty as they facilitate shared decision making and delineate goals of care based on patient and/or family values.
List specific
Knowledge
• Describe prognostication in serious illness, identifying elements of history, physical
exam, and diagnostic testing important to determining prognosis.
• List current prognostic methods and tools and the strengths and weaknesses of each
approach.
• Describe techniques for communicating prognosis and medical uncertainty across the
age spectrum, from pediatrics to geriatrics.
Skills
• Perform a thoughtful, comprehensive, and systematic palliative care assessment
taking into account disease process, comorbidities, disease trajectory, psychosocial
support, and available treatments.
• Use relevant evidence-based prognostic tools to help create a prognostic estimate
when appropriate.
• Obtain and integrate prognostic estimates from other healthcare providers.
• Determine hospice eligibility based on a prognostic estimate.
• Assess patient and/or family interest in knowing prognostic information and explore
the specific reasons for preferences, including cultural and/or spiritual influences.
• Assess and communicate disease trajectory, expected function, and prognosis to
patients, families, and other healthcare providers.
• Acknowledge and express uncertainty.
• Direct a family meeting when necessary to help communicate prognosis and aid
medical decision making.
Attitudes
• Appreciate the importance of prognosis in medical decision making and the weight of
prognosis for all involved.
• Appreciate the challenge of uncertainty in prognostication across various patient
populations.
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Hospice & Palliative Medicine EPA Title: EPA 5. Establish goals of care based on patient and/or Hospice & Palliative Medicine EPA Title: EPA 5. Establish goals of care based on patient and/or Hospice & Palliative Medicine EPA Title: EPA 5. Establish goals of care based on patient and/or Hospice & Palliative Medicine EPA Title: EPA 5. Establish goals of care based on patient and/or
family values and specific medical circumstances.family values and specific medical circumstances.family values and specific medical circumstances.family values and specific medical circumstances.
Detailed Description: HPM physicians elicit patient/family values, delineate goals of care based on patient and/or
family values in the context of the patient’s medical condition, and make recommendations for an appropriate care
plan.
List specific
Knowledge
• Describe prognostication in serious illness.
• Recognize techniques for communicating prognosis and medical uncertainty.
• Explain and differentiate essential elements of assessing decision-making capacity
across the age spectrum.
• Identify techniques for engaging patients and family members in discussion and
conflict resolution.
• Relate patient- and family-centered communication to delineation of goals of care,
particularly in the determination of patient and/or family values.
• Describe the benefits and burdens of various medical therapies.
• Differentiate curative versus palliative intent of treatments.
• Define the concurrent care model which allows for coexisting curative and palliative
goals of care in pediatric hospice and other similar settings.
Skills
• Perform a thoughtful, comprehensive, and systematic palliative assessment, taking
into account disease process, comorbidities, characteristic symptom burden, and
disease trajectory, together with input from other healthcare providers.
• Direct a family meeting to help set goals of care, communicate prognosis, reframe
hope, and express uncertainty.
• Use a framework approach to give serious news or medical information, attending to
emotion from the patient, family and other healthcare providers.
• Establish the patient’s definition and determinants of quality of life.
• Utilize the interdisciplinary team to explore and clarify patient and/or family values.
• Provide recommendations for medical care based on patient and/or family values
and goals.
• Discuss withdrawal of medical therapies such as artificial hydration and nutrition,
antibiotics, anticoagulation, or other medications based on goals of care.
• Work toward consensus among patients, families, and healthcare providers.
• Assist with conflict resolution between patients, families, and other healthcare
providers.
• Guide patients, families, and healthcare providers through the shifting transitions
between curative and palliative care.
• Introduce hospice care when appropriate based on overall prognosis.
Attitudes
• Appreciate the importance of determining and communicating prognosis to aid
medical decision making.
• Respect individual patient and/or family differences in hopes and values related to
serious illness.
• Anticipate the full spectrum of patient and family responses to goals of care
discussions.
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Hospice & Palliative Medicine EPA Title: EPA 6. Participate as a member or leader of an Hospice & Palliative Medicine EPA Title: EPA 6. Participate as a member or leader of an Hospice & Palliative Medicine EPA Title: EPA 6. Participate as a member or leader of an Hospice & Palliative Medicine EPA Title: EPA 6. Participate as a member or leader of an
interdisciplinary team.interdisciplinary team.interdisciplinary team.interdisciplinary team.
Detailed Description: HPM physicians manage the medical care provided by interdisciplinary teams (IDTs) and facilitate
IDT meetings while sharing the leadership role with other IDT members as appropriate.
List specific
Knowledge
• Describe concepts of team processes and development and recognize elements that
promote or hinder successful IDT function.
• Discuss the professional skill set, expertise, role, and potential contribution of each
member of the interdisciplinary team.
Skills
• Lead and/or facilitate recurring IDT meetings.
• Evolve one’s own communication style with colleagues to optimize team function
within and outside of IDT meetings.
• Accept and solicit insights from all IDT members in developing a patient care plan.
• Monitor and facilitate team function including managing distress and supporting
resilience.
• Provide and accept feedback from IDT members.
• Help to develop the care plan and/or provide care to patients and families as a
member of an IDT.
Attitudes
• Respect the unique contributions of each member of the IDT and the impact of each
member on team function.
• Recognize the need to address all palliative care domains in the development of an
effective care plan.
• Facilitate openness, receptivity, mutual respect, and trust among IDT members.
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Hospice & Palliative MediHospice & Palliative MediHospice & Palliative MediHospice & Palliative Medicine Title: EPA 7. Prevent and mediate conflict and distress over cine Title: EPA 7. Prevent and mediate conflict and distress over cine Title: EPA 7. Prevent and mediate conflict and distress over cine Title: EPA 7. Prevent and mediate conflict and distress over
complex medical decisions.complex medical decisions.complex medical decisions.complex medical decisions.
Detailed Description: HPM physicians prevent and address clinical conflict, uncertainty, emotionally charged
encounters, and value-laden suffering through advanced palliative communication techniques.
List specific
Knowledge
• Describe treatment options and prognosis; indicators and impact of patient, family,
provider, and team distress; and ethical and legal implications of decisions.
• Recall and understand the situations and decisions that lead to clinical conflict.
Skills
• Acknowledge and negotiate contentious clinical situations.
• Identify, recognize sources of, and formulate a differential diagnosis for the conflict,
engaging the assistance of the interdisciplinary team as needed.
• Identify and attend to strongly expressed opinions and emotions; help to de-escalate
situations in which conflict intensifies.
• Attend to the emotional and physical safety of providers, patients, and families in
conflict situations.
• Compassionately and realistically mediate disagreements regarding care plans.
• Address current or anticipated grief among patients, families, providers, and teams,
especially as it pertains to clinical decision making.
• Elucidate and address the ethical and legal implications of difficult decisions to be
made when disagreement exists.
• Address conflict in a step-wise process (recognition, preparation, identification of
involved/violated core concerns, exploration, reframing, alliance, support, and
compromise) with the assistance of the team as needed.
• Direct a family meeting to help address conflict and distress when necessary.
Attitudes
• Demonstrate openness to patient and family preferences.
• Display commitment to meeting patient needs while preserving provider integrity.
• Exhibit self-awareness of personal values, how they might conflict with others’
values, and how they impact conflict mediation.
• Demonstrate openness to identifying one’s own strong positive and/or negative
feelings.
• Reflect on negative emotions in oneself and one’s patients over time.
• Exhibit compassion for all disciplines and specialties involved in difficult patient-care
situations.
• Display humility regarding one’s own clinical judgment and openness to other
opinions in charged clinical situations.
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Hospice & Palliative Medicine EPA Title: EPA 8. Manage withdrawal of advanced lifeHospice & Palliative Medicine EPA Title: EPA 8. Manage withdrawal of advanced lifeHospice & Palliative Medicine EPA Title: EPA 8. Manage withdrawal of advanced lifeHospice & Palliative Medicine EPA Title: EPA 8. Manage withdrawal of advanced life----sustaining sustaining sustaining sustaining
therapies.therapies.therapies.therapies.
Detailed Description: HPM physicians are skilled in the withdrawal of advanced life-sustaining therapies (LSTs),
including facilitation of goals of care discussions leading to the decision to withdraw advanced LST, management of
symptoms before and after withdrawal of advanced LST, orchestration of withdrawal of LST, and provision of family
support for psychosocial and spiritual distress including anticipatory grief and bereavement.
List specific
Knowledge
• Describe the federal, state, and local laws that impact the withdrawal of advanced
LST.
• Give examples of ethical principles relevant to the withdrawal of advanced LST.
• Discuss local institutional policies relevant to the process of withdrawal of advanced
LST.
• Explain the process of withdrawal of various advanced LSTs.
• Describe symptom burden and appropriate interventions associated with withdrawal
of common advanced LSTs.
• Recognize signs and symptoms of impending death after withdrawal of advanced
LST.
• Recognize psychosocial and spiritual distress including anticipatory grief and
bereavement responses from families.
Skills
• Facilitate discussions with patients and/or families regarding goals of care and
preparation for withdrawal of advanced LST.
• Diagnose and manage symptom burdens associated with withdrawal of advanced
LST.
• Orchestrate withdrawal of advanced LST.
• Attend to psychosocial and spiritual distress including anticipatory grief and
bereavement responses from families.
• Utilize the interdisciplinary team (IDT) to support both the patient and family before,
during, and after the withdrawal of LST.
• Demonstrate care that shows respectful attention to sociocultural characteristics of
patients and their families.
• Demonstrate high standards of ethical behavior including utilizing the IDT,
maintaining professional boundaries and scope of practice, and collaborating with
other involved physicians and healthcare providers.
Attitudes
• Appreciate the need to attend to unique characteristics and needs of patients, their
families, and healthcare providers.
• Value the key roles of IDT members, collaboration with colleagues, and maintenance
of professional boundaries in withdrawal of LST.
• Appreciate the potential gravity of decisions to withdraw LST.
• Accept that personal experiences and the specific microculture of the care setting
can contribute to bias, which can impact the recommendation to withdraw LST.
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Hospice & Palliative Medicine EPA Title: EPA 9. Care for imminently dying patients and their Hospice & Palliative Medicine EPA Title: EPA 9. Care for imminently dying patients and their Hospice & Palliative Medicine EPA Title: EPA 9. Care for imminently dying patients and their Hospice & Palliative Medicine EPA Title: EPA 9. Care for imminently dying patients and their
families.families.families.families.
Detailed Description: HPM physicians identify signs of the dying process, address multiple areas of suffering for the
imminently dying patient and their family and facilitate after-death bereavement support for the family and healthcare
providers.
List specific
Knowledge
• Describe the physical signs and symptoms of the dying process and common
challenges for symptom management.
• List medications used to treat symptoms of impending death and explain their
mechanisms of action.
• Describe areas of whole-patient care as it relates to caring for the imminently dying
patient.
• Recognize roles and skills of interdisciplinary team members needed to achieve
whole-patient care.
• Describe communication techniques to provide psychosocial support.
• Recall and explain the range of potential indications for proportionate symptom
control, which could include sedation.
• Describe ethical principles and how they do or do not apply to end-of-life care.
• Identify the characteristics of normal and complicated grief and bereavement.
• List medical conditions that require medical examiner involvement and requisite
steps of sensitive death pronouncement and documentation.
Skills
• Recognize the imminently dying patient and associated signs and symptoms.
• Facilitate communication to prepare family and healthcare providers that death is
imminent.
• Utilize an interdisciplinary team approach to provide whole-patient care for the
imminently dying patient and their family.
• Provide psychosocial support to family and healthcare providers regarding common
concerns, identify family members at risk for complex bereavement, and have
patience and understanding for different coping and grieving styles.
• Recognize different perspectives of family and healthcare providers regarding the
degree of symptom burden during the dying process.
• Manage physical symptoms of impending death.
• Inquire if spiritual or cultural rituals are important and provide assistance as
appropriate.
• Make the death pronouncement in a sensitive, respectful way in the presence of
family.
• Document the patient’s death and complete the death certificate appropriately.
Attitudes
• Appreciate the importance and time sensitivity in providing care for the imminently
dying patient and their family.
• Acknowledge the uniqueness of the dying experience for each patient and family.
• Value the potential positive impact of effective interdisciplinary care on family
bereavement.
• Recognize the importance of role modeling and teaching sensitive, skilled care of the
dying patient to other care providers.
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Hospice & Palliative Medicine EPA Title: EPA 10. Address requests for hastened death.Hospice & Palliative Medicine EPA Title: EPA 10. Address requests for hastened death.Hospice & Palliative Medicine EPA Title: EPA 10. Address requests for hastened death.Hospice & Palliative Medicine EPA Title: EPA 10. Address requests for hastened death.
Detailed Description: HPM physicians address requests for hastened death in accordance with federal, state, and
local regulations as well as ethical and professional principles while remaining sensitive to a patient's individual values,
preferences, and sources of suffering.
List specific
Knowledge
• Identify and summarize the federal and state laws, local regulations, and professional
guidelines applicable to requests for hastened death.
• Demonstrate broad knowledge of epidemiology and etiologies of requests for
hastened death.
• Elucidate a physician’s clinical, ethical, and professional responsibilities when faced
with requests for hastened death.
• List and explain bioethical models relevant to requests for hastened death.
Skills
• Explore the full range of potential motivations in requests for hastened death using a
routine and comprehensive approach.
• Communicate and counsel the patient about total pain, and provide state-of-the-art
palliative therapies to manage total pain by addressing all aspects of suffering with
time-limited trials.
• Explore the patient’s fears and expectations and facilitate establishing individual
goals when hastened death is requested.
• Maintain meticulous, interdisciplinary records of requests for hastened death.
Attitudes
• Appreciate the importance of the federal and state laws, local regulations, and
professional guidelines related to requests for hastened death.
• Remain mindful of the limits of medicine and a physician’s ability to relieve suffering.
• Seek awareness of and be willing to balance one’s own and others’ fundamental
values regarding requests for hastened death.
• Be open to consideration of competing claims to safeguard human life and individual
autonomy, and be prepared to reconsider previous opinions in light of new evidence
or arguments.
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Hospice & Palliative Hospice & Palliative Hospice & Palliative Hospice & Palliative Medicine EPA Title: EPA 11. SMedicine EPA Title: EPA 11. SMedicine EPA Title: EPA 11. SMedicine EPA Title: EPA 11. Support patients and families in the upport patients and families in the upport patients and families in the upport patients and families in the
psychosocial domain.psychosocial domain.psychosocial domain.psychosocial domain.
Detailed Description: HPM physicians address patient and family suffering, coping, and healing within the emotional,
psychological, and social domains with focused, developmentally appropriate assessment followed by targeted
communication, interventions, and referrals.
List specific
Knowledge
• Describe approaches to developmentally appropriate assessment for coping,
stressors, grief and bereavement, suffering, and behavioral health comorbidities.
• Identify techniques for expressing empathy.
• Describe how issues involving cultural sensitivity and diversity affect access to and
utilization of hospice and palliative care.
• Discuss benefits, burdens, and risks for the caregiver role.
• Identify specific roles, expertise, and supportive interventions that individual team
members, especially psychosocial clinicians, can provide in support of patients and
families.
• List potential referrals and additional resources in various clinical settings.
Skills
• Elicit a focused, developmentally appropriate psychosocial history, tailored to each
patient and family.
• Assess for coping, stressors, grief and bereavement, suffering, behavioral health
comorbidities, and caregiver burden.
• Provide basic counseling, empathetic response, and cultural sensitivity in supporting
expressions of distress.
• Develop appropriate patient- and family-centered assessments, communication, and
care plans with the interdisciplinary team (IDT), especially psychosocial clinicians
when available.
• Mobilize additional resources, make referrals, and navigate the healthcare system to
meet patient and family needs.
Attitudes
• Appreciate the contribution of the psychosocial domain to patient and family coping,
suffering, resilience, healing, well-being, and bereavement.
• Value the expertise of IDT members in formulating assessments and care plans for
patient and family support.
• Prioritize developmentally appropriate and culturally sensitive patient and family
care.
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Hospice & Palliative Medicine EPA Title: EPA 12. Support patients and families in the spiritual and Hospice & Palliative Medicine EPA Title: EPA 12. Support patients and families in the spiritual and Hospice & Palliative Medicine EPA Title: EPA 12. Support patients and families in the spiritual and Hospice & Palliative Medicine EPA Title: EPA 12. Support patients and families in the spiritual and
existential domain.existential domain.existential domain.existential domain.
Detailed Description: HPM physicians address patient and family suffering and identify strengths and needs within the
spiritual and existential domain with basic assessment followed by appropriate interventions and referrals.
List specific
Knowledge
• Describe approaches to screening and basic history taking of spirituality, religion,
existential issues, and issues of meaning and purpose.
• Discuss types and causes of spiritual distress.
• Identify interventions the physician and/or interdisciplinary team (IDT) can provide
depending on patient, family, and team composition and characteristics.
• Distinguish expertise that individual team members, especially chaplains, can provide
in support of patients and families.
• List potential referrals and additional resources in various clinical settings.
Skills
• Provide compassionate presence and listening.
• Offer open, empathetic response to spiritual and existential suffering.
• Take a basic spiritual history tailored to each patient and family.
• Explore how patient and family spiritual, religious, and existential beliefs and values
affect medical decision making and the provision of health care.
• Inquire about and support patients’ and families’ end-of-life spiritual and/or religious
practices and rituals.
• Assist the IDT in identifying and promoting a sense of meaning and purpose and
creation of legacy.
• Develop appropriate patient- and family-centered assessments and care plans with
the IDT, especially the chaplain when available.
• Engage community clergy and, when appropriate, mobilize additional resources,
make referrals, and navigate through the healthcare system to effectively meet
patient and family needs.
Attitudes
• Appreciate the contribution of the spiritual and existential domain to patient and
family coping, suffering, resilience, healing, well-being, and bereavement.
• Respect patients’ and families’ spiritual, religious, and existential beliefs even if these
beliefs and values contradict one’s own beliefs and values.
• Value expertise of IDT members in formulating assessments and care plans for
patient and family support.
• Be open to working with spiritual providers of diverse backgrounds and belief
systems.
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Hospice & Palliative Medicine EPA Title: EPA 13. Promote selfHospice & Palliative Medicine EPA Title: EPA 13. Promote selfHospice & Palliative Medicine EPA Title: EPA 13. Promote selfHospice & Palliative Medicine EPA Title: EPA 13. Promote self----care and resiliencecare and resiliencecare and resiliencecare and resilience....
Detailed Description: HPM physicians value and promote resilience and personal well-being for themselves and others
as a necessary element for professional success and sustainability.
List specific
Knowledge
• Understand the impact from personal and professional losses on oneself and others.
• Give examples and describe features of burnout, moral distress, compassion fatigue,
depersonalization, inefficacy, and vicarious trauma.
• Recall factors that predispose individuals and teams to stress and burnout.
• Describe strategies to mitigate physical and emotional exhaustion, foster professional
and personal growth and identity, promote compassion and equanimity, and
strengthen resilience.
Skills
• Develop awareness of one’s own subjective experience and the work environment in
order to achieve balance with the needs of patients and their families.
• Remain present to suffering of others and maintain resilience when experiencing
one’s own distress and/or grief.
• Develop practices that promote regular reflections toward growth and self-care.
• Recognize risks for and features of excessive stress, impairment, and impending
burnout in oneself and others.
Attitudes
• Appreciate the importance of and professional responsibility to attend to self-care.
• Value the need for balance around resilience and grief/bereavement.
• Utilize self-care tools and engage in strategies to mitigate physical and emotional
exhaustion, cynicism, and inefficacy.
• Promote highly present, boundary-conscious, empathetic engagement.
• Role model and encourage effective self-care for other trainees.
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Hospice & Palliative Medicine EPA Title: EPA 14. Facilitate transitions across the HPM contHospice & Palliative Medicine EPA Title: EPA 14. Facilitate transitions across the HPM contHospice & Palliative Medicine EPA Title: EPA 14. Facilitate transitions across the HPM contHospice & Palliative Medicine EPA Title: EPA 14. Facilitate transitions across the HPM continuum inuum inuum inuum
of care.of care.of care.of care.
Detailed Description: HPM physicians are adept at caring for patients and families across the healthcare continuum
(eg, inpatient, long-term care, ambulatory, home) with an understanding of and appreciation for resource availability,
care coordination, and transitions support required for effective and high-quality care.
List specific
Knowledge
• Describe various settings in which patients and families may access palliative care.
• Discuss common characteristics of interdisciplinary team (IDT) resources and staffing
available in different settings to meet patient and family needs around acuity and
distress.
• Identify the range of diagnostic approaches and therapies that can be maintained in
various care settings.
• Define systems-based reimbursement and payment structures, eligibility
requirements, and key regulations in different care settings.
• Recognize potential gaps in care as patients transition between settings, including
communication between providers, medication reconciliation, treatments, and
emotional support for patients and families.
Skills
• Select and dose medications based on accessibility and availability of route of
administration within and across care settings.
• Initiate and adjust medical interventions germane to specific care settings.
• Communicate with IDT, primary service, consultants, and other providers within and
across care settings.
• Assess appropriateness of patients for specific care settings, clarifying necessary and
available resources, and constructing transition plans that incorporate patient safety
while aligning with patient and family goals.
• Provide guidance for smooth transitions across settings for patients, families, and
providers that address medical, pharmaceutical, social, emotional, and spiritual
concerns.
Attitudes
• Recognize challenges to patients, families, and providers in confronting differing
formularies and costs of treatments across the continuum.
• Demonstrate appreciation for the culture and structure of each care setting and the
need to work with their strengths and limitations to best meet patient and family
goals.
• Recognize that care teams have their own values regarding care settings, which may
influence their recommendations.
• Demonstrate appreciation for the roles of different healthcare team members in
various care settings.
• Empathize with patient and family distress surrounding times of transition between
care settings.
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Hospice & Palliative Medicine EPA Title: EPA 15. Fulfill the role of a hospice medical director.Hospice & Palliative Medicine EPA Title: EPA 15. Fulfill the role of a hospice medical director.Hospice & Palliative Medicine EPA Title: EPA 15. Fulfill the role of a hospice medical director.Hospice & Palliative Medicine EPA Title: EPA 15. Fulfill the role of a hospice medical director.
Detailed Description: HPM physicians meet the clinical, regulatory, administrative, and supportive responsibilities of a
hospice medical director.
List specific
Knowledge
• Describe hospice eligibility guidelines for common medical conditions, and pediatric
patients, including concurrent care models.
• Identify specialty-level pain and symptom management expertise specific to the
unique settings and requirements for hospice care.
• Discuss hospice regulatory requirements.
• Explain how hospice integrates into local, regional, and national health care.
• Monitor and identify financial issues affecting hospice programs, including public and
private reimbursement and payment structures and philanthropy.
• Outline the appeals process for denied claims
Skills
• Provide hospice care to patients and families across diverse settings: home, long-
term care, and inpatient hospice.
• Facilitate a hospice interdisciplinary team (IDT) meeting
• Comply with regulatory requirements and documentation including Certification of
Terminal illness, Face to Face, etc.
• Provide leadership, education, and support to hospice IDT members.
• Manage medications with formulary restrictions.
• Work with hospice patients’ primary- and specialty-care providers.
• Engage pediatric palliative care resources to serve pediatric hospice patients.
• Work telephonically with hospice staff, patients, and families in critical situations.
• Ensure the safety of oneself and staff when working in challenging environments.
Attitudes
• Respect the skills and knowledge of diverse disciplines working to help patients and
families.
• Appreciate the diverse cultural, socioeconomic, and ethnic backgrounds of patients.
• Display openness to collaboration and teamwork.
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Hospice & Palliative Medicine EPA Title: EPA 16. Provide HPM consultation and teaHospice & Palliative Medicine EPA Title: EPA 16. Provide HPM consultation and teaHospice & Palliative Medicine EPA Title: EPA 16. Provide HPM consultation and teaHospice & Palliative Medicine EPA Title: EPA 16. Provide HPM consultation and team support.m support.m support.m support.
Detailed Description: HPM physicians render patient- and family-centered consultative care in a professional, timely,
and effective manner that supports and educates the referring and invested team members.
List specific
Knowledge
• Recognize the roles of different interdisciplinary team members.
• Educate others on appropriate indications for palliative care consultation.
• Describe consultation etiquette.
• Recognize that comprehensive care of a patient routinely involves attention to
physical, emotional, psychosocial, and spiritual elements.
• Identify provider distress.
• Recognize the dual and sometimes conflicting roles of patient/family advocate and
consultant.
Skills
• Gather and synthesize essential and accurate information relevant to the consult,
including clarification of the consultation question when needed.
• Introduce and educate about the role of palliative care and hospice.
• Perform a palliative medicine–focused history and physical.
• Use available evidence to construct a palliative care assessment and management
plan.
• Seek answers to outstanding patient, family, and clinical questions that arise in the
course of consultation.
• Seek to understand, maintain rapport, and advocate for patient and family goals
when healthcare providers have conflicting views.
• Respond to provider distress with empathy.
• Timely and effectively Communicate recommendations to patients, families, and
referring providers and document these in the patient’s medical record in a time-
sensitive and effective manner.
• Engage the strengths and skills of IDT members.
• Support other teams in developing their palliative care skills.
Attitudes
• Exemplify professional and ethical behavior.
• Appreciate evidence-based medicine.
• Welcome and incorporate feedback from referring teams.
• Value patient advocacy.
• Show concern for provider and team well-being and needs.
• Appreciate the relationship between consultation etiquette and future referrals.
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Hospice & Palliative Medicine EPA Title: EPA 17. Hospice & Palliative Medicine EPA Title: EPA 17. Hospice & Palliative Medicine EPA Title: EPA 17. Hospice & Palliative Medicine EPA Title: EPA 17. Promote and teach hospice and palliative Promote and teach hospice and palliative Promote and teach hospice and palliative Promote and teach hospice and palliative care.care.care.care.
Detailed Description: HPM physicians promote access to high-quality palliative care services across the continuum of
care through advocacy and health system improvement as well as by teaching hospice and palliative care to other
healthcare providers.
List specific
Knowledge
• Describe the value and role of palliative and hospice care accounting for diversity of
learning needs, backgrounds, learning styles, and education levels among patients,
families, community members, and others.
• Identify educational needs of interprofessional colleagues, administrators, medical
staff, and peers regarding the basics of hospice and palliative care for all healthcare
providers.
• Describe the key roles of specialty HPM in the healthcare delivery system.
• Describe how to integrate quality improvement activities into the routine function of
palliative and hospice programs.
Skills
• Demonstrate the ability to critically appraise, disseminate, and apply palliative care
literature.
• Advocate for palliative care program development within systems.
• Promote hospice and palliative care education within healthcare
systems/organizations.
• Identify key stakeholders in local and system-level healthcare improvement efforts.
• Deliver a succinct message to both community and professional audiences about the
importance of hospice and palliative care for optimal patient care.
• Adapt different teaching formats based on the setting, content, and learners.
• Analyze clinical performance data and actively work to improve performance.
• Model lifelong learning in palliative care.
Attitudes
• Appreciate that basic palliative care skills are an essential competency for all health
professionals.
• Recognize the responsibility to serve as a palliative care educator to patients,
families, and the community.
• Appreciate the need to use meaningful metrics for hospice and palliative care
program development.
• Value advocacy (local, regional, national) as a means to improve quality health care
for patients and families.
• Remain open to feedback at the individual, programmatic, and system level.
• Value quality improvement as a tool to grow and improve palliative care programs.