EE
PP
EE
CC
OO
Linda L. Emanuel, MD, PhDLinda L. Emanuel, MD, PhD
PrincipalPrincipal
Jamie H. Von Roenn, MDJamie H. Von Ro...
Outline
Policy backgroundPolicy background
Charles von Gunten, MD, PhDCharles von Gunten, MD, PhD
The EPEC ProjectThe EPEC...
EE
PP
EE
CC
OO
Charles F von Gunten, MD PhDCharles F von Gunten, MD PhD
Director, Palliative CareDirector, Palliative Care...
Institute of Medicine,
1997
Approaching Death:
Improving Care at the End of Life
www.nas.edu/iom 
ASCO, 1998
Oncologists’ responsibility to care for aOncologists’ responsibility to care for a
patient in a continuum from ...
National Cancer PolicyNational Cancer Policy
Board Report , 1999Board Report , 1999
““RECOMMENDATIONRECOMMENDATION
5: Ensu...
National Cancer PolicyNational Cancer Policy
Board Report , 2001Board Report , 2001
Part I: SummaryPart I: Summary
and Ten...
“NCI-designated cancer
centers should play a central
role as agents of national
policy in advancing palliative
care resear...
Recommendation 6:
Best availableBest available
practicepractice
guidelinesguidelines
should dictateshould dictate
the stan...
Professional societies,
particularly the American
Society of Clinical Oncology, …
should provide leadership and
training f...
Summary from Policy
Background
NCI and ASCO leadership neededNCI and ASCO leadership needed
Make best evidence practically...
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The EPEC Project:
Education for Physicians on
End-of-life Care
Frank D. FerrisFrank D. Ferris
Co-Principal,...
Background
SUPPORT Study, 1995SUPPORT Study, 1995
Lack of physicianLack of physician
competency in end-of-lifecompetency i...
Method
Core CurriculumCore Curriculum
Train-the-trainerTrain-the-trainer
disseminationdissemination
Exposure for everyExpo...
EPEC Materials
Consensus of expertsConsensus of experts
Session Format
4 Plenaries – large group4 Plenaries – large group
Session Format
12 Modules – small groups12 Modules – small groups
EPEC Materials
Trigger TapesTrigger Tapes
Trainer’s GuideTrainer’s Guide
Participants’ HandbookParticipants’ Handbook
Slid...
Estimated Reach of EPEC
Training of first 555
trainers in 2 years
6,800 training sessions6,800 training sessions
120,900 h...
www.EPEC.net
Summary from EPEC
Project
Model for dissemination of newModel for dissemination of new
informationinformation
Best educati...
EE
PP
EE
CC
OO
EPEC-O Project
Charles F von Gunten, MD, PHD
Associate Professor of Medicine
Moores’ Comprehensive Cancer C...
Background to EPEC-O
ASCO with commitment to palliativeASCO with commitment to palliative
care throughout the course of th...
Background to EPEC-O
Adapt EPECAdapt EPEC
Best scientific evidenceBest scientific evidence
Best education scienceBest educ...
Imagine
EE
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Gaps in Cancer
Care
Plenary 1Plenary 1
EPEC - Oncology
Supported by the
National Cancer Institute
American ...
Principle message
Gaps between current and desiredGaps between current and desired
practice need to be filled so thatpract...
Outline
Describe the current state ofDescribe the current state of
palliative care in cancerpalliative care in cancer
Pati...
EE
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Trigger Video
Palliative Care
Treatment to relieve pain and suffering.Treatment to relieve pain and suffering.
May beMay be combinedcomb...
Conventional Cancer Care
PresentationPresentation DeathDeath
Anti-neoplastic TherapyAnti-neoplastic Therapy
BereavementBer...
Comprehensive Cancer Care
PresentationPresentation DeathDeath
Anti-neoplastic TherapyAnti-neoplastic Therapy
BereavementBe...
Gaps
FearsFears
Pain & SufferingPain & Suffering
Be a burdenBe a burden
Loss of controlLoss of control
DesiresDesires
Be c...
1998 ASCO Survey
6,645 oncologists surveyed6,645 oncologists surveyed
118 questions118 questions
n = 3227 (48% response ra...
Source of Information about
palliative care
90% Trial and Error90% Trial and Error
73% Colleagues and role models73% Colle...
Inadequate education about
palliative care
81% inadequate mentor or coaching81% inadequate mentor or coaching
in how to di...
Personal Failure
76% feel some sense of personal76% feel some sense of personal
failure if patient dies of cancerfailure i...
Unrealistic Expectations
29% Patient29% Patient
50% Family50% Family
27% Conflict27% Conflict
At least some Influence
97% Oncologists reluctant to ‘give up’97% Oncologists reluctant to ‘give up’
99% Patient / family ...
Professional Satisfaction
98% some emotional satisfaction to98% some emotional satisfaction to
provide palliative careprov...
Outline
Describe the current state ofDescribe the current state of
palliative care in cancerpalliative care in cancer
Pati...
Goals of EPEC-O
Practicing oncologistsPracticing oncologists
Core clinical skillsCore clinical skills
ImproveImprove
compe...
EPEC-O Curriculum . . .
conflict resolutionconflict resolution
clinical trials – phase Iclinical trials – phase I
preventi...
EPEC-O Curriculum . . .
symptom managementsymptom management
diagnosis and prognosisdiagnosis and prognosis
advance care p...
EPEC-O Curriculum . . .
physician-assisted suicide /physician-assisted suicide /
euthanasiaeuthanasia
withholding and with...
EPEC-O Curriculum . . .
how to teachhow to teach
models of palliative caremodels of palliative care
Next steps to improve ...
. . EPEC-O Curriculum
apply each skill in your practiceapply each skill in your practice
enhance professional satisfaction...
EE
PP
EE
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SummarySummary
Gaps need to be filled so thatGaps need to be filled so that
palliative care becomes anpalli...
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    1. 1. EE PP EE CC OO Linda L. Emanuel, MD, PhDLinda L. Emanuel, MD, PhD PrincipalPrincipal Jamie H. Von Roenn, MDJamie H. Von Roenn, MD Charles F. von Gunten, MD, PhDCharles F. von Gunten, MD, PhD Co-PrincipalsCo-Principals Frank D. Ferris, MDFrank D. Ferris, MD EditorEditor EPEC - OEducation on Palliative and End-of-life Care -Oncology EPEC - Oncology Supported by the National Cancer Institute American Society for Clinical Oncology
    2. 2. Outline Policy backgroundPolicy background Charles von Gunten, MD, PhDCharles von Gunten, MD, PhD The EPEC ProjectThe EPEC Project Frank Ferris, MDFrank Ferris, MD Introduce the EPEC-O ProjectIntroduce the EPEC-O Project Charles F von GuntenCharles F von Gunten
    3. 3. EE PP EE CC OO Charles F von Gunten, MD PhDCharles F von Gunten, MD PhD Director, Palliative CareDirector, Palliative Care Associate Professor of MedicineAssociate Professor of Medicine University of California, San DiegoUniversity of California, San Diego Policy Background EPEC - Oncology Supported by the National Cancer Institute American Society for Clinical Oncology
    4. 4. Institute of Medicine, 1997 Approaching Death: Improving Care at the End of Life www.nas.edu/iom 
    5. 5. ASCO, 1998 Oncologists’ responsibility to care for aOncologists’ responsibility to care for a patient in a continuum from diagnosispatient in a continuum from diagnosis throughout the course of the illness.throughout the course of the illness. In addition to appropriate anticancerIn addition to appropriate anticancer treatment, this includes symptomtreatment, this includes symptom control and psychosocial supportcontrol and psychosocial support during all phases of care, includingduring all phases of care, including those during the last phase of life.those during the last phase of life. J Clin Oncol 1998;16:1986-96 
    6. 6. National Cancer PolicyNational Cancer Policy Board Report , 1999Board Report , 1999 ““RECOMMENDATIONRECOMMENDATION 5: Ensure quality of5: Ensure quality of care at the end ofcare at the end of life, in particular, thelife, in particular, the management ofmanagement of cancer-related paincancer-related pain and timely referral toand timely referral to palliative andpalliative and hospice care.”hospice care.”
    7. 7. National Cancer PolicyNational Cancer Policy Board Report , 2001Board Report , 2001 Part I: SummaryPart I: Summary and Tenand Ten RecommendationsRecommendations Part II: EightPart II: Eight CommissionedCommissioned ChaptersChapters www.iom.eduwww.iom.edu
    8. 8. “NCI-designated cancer centers should play a central role as agents of national policy in advancing palliative care research and clinical practice, with initiatives that address many of the barriers identified in this report.”
    9. 9. Recommendation 6: Best availableBest available practicepractice guidelinesguidelines should dictateshould dictate the standard ofthe standard of care for bothcare for both physical andphysical and psychosocialpsychosocial symptoms.symptoms.
    10. 10. Professional societies, particularly the American Society of Clinical Oncology, … should provide leadership and training for nonspecialists, who provide most of the care for cancer patients. …Recommendation 6
    11. 11. Summary from Policy Background NCI and ASCO leadership neededNCI and ASCO leadership needed Make best evidence practicallyMake best evidence practically availableavailable Role of oncologists as teachersRole of oncologists as teachers
    12. 12. EE PP EE CC OO The EPEC Project: Education for Physicians on End-of-life Care Frank D. FerrisFrank D. Ferris Co-Principal, The EPEC ProjectCo-Principal, The EPEC Project Professor of MedicineProfessor of Medicine University of California, San DiegoUniversity of California, San Diego
    13. 13. Background SUPPORT Study, 1995SUPPORT Study, 1995 Lack of physicianLack of physician competency in end-of-lifecompetency in end-of-life carecare Target: 440,000 practicingTarget: 440,000 practicing physicians in the USphysicians in the US
    14. 14. Method Core CurriculumCore Curriculum Train-the-trainerTrain-the-trainer disseminationdissemination Exposure for everyExposure for every practicing physicianpracticing physician
    15. 15. EPEC Materials Consensus of expertsConsensus of experts
    16. 16. Session Format 4 Plenaries – large group4 Plenaries – large group
    17. 17. Session Format 12 Modules – small groups12 Modules – small groups
    18. 18. EPEC Materials Trigger TapesTrigger Tapes Trainer’s GuideTrainer’s Guide Participants’ HandbookParticipants’ Handbook Slide SetsSlide Sets PowerPointPowerPoint Reproduce with attributionReproduce with attribution
    19. 19. Estimated Reach of EPEC Training of first 555 trainers in 2 years 6,800 training sessions6,800 training sessions 120,900 health professionals120,900 health professionals 83,138 physicians, residents, medical83,138 physicians, residents, medical studentsstudents
    20. 20. www.EPEC.net
    21. 21. Summary from EPEC Project Model for dissemination of newModel for dissemination of new informationinformation Best education science as well asBest education science as well as best medical sciencebest medical science Doctors as teachersDoctors as teachers
    22. 22. EE PP EE CC OO EPEC-O Project Charles F von Gunten, MD, PHD Associate Professor of Medicine Moores’ Comprehensive Cancer Center, UCSD Medical Director Center for Palliative Studies San Diego Hospice & Palliative Care IntroductionIntroduction EPEC - Oncology Supported by the National Cancer Institute American Society for Clinical Oncology
    23. 23. Background to EPEC-O ASCO with commitment to palliativeASCO with commitment to palliative care throughout the course of thecare throughout the course of the diseasedisease NCI to ‘eliminate suffering and deathNCI to ‘eliminate suffering and death by 2015’by 2015’ Oncologists frequently called uponOncologists frequently called upon to teach palliative careto teach palliative care
    24. 24. Background to EPEC-O Adapt EPECAdapt EPEC Best scientific evidenceBest scientific evidence Best education scienceBest education science Train-the-trainerTrain-the-trainer Easy to use and flexible materialsEasy to use and flexible materials Incorporate Oncology-specificIncorporate Oncology-specific issuesissues
    25. 25. Imagine
    26. 26. EE PP EE CC OO Gaps in Cancer Care Plenary 1Plenary 1 EPEC - Oncology Supported by the National Cancer Institute American Society for Clinical Oncology
    27. 27. Principle message Gaps between current and desiredGaps between current and desired practice need to be filled so thatpractice need to be filled so that palliative care becomes an essentialpalliative care becomes an essential and inextricable part ofand inextricable part of comprehensive cancer carecomprehensive cancer care
    28. 28. Outline Describe the current state ofDescribe the current state of palliative care in cancerpalliative care in cancer Patients / familiesPatients / families OncologistsOncologists Describe what is neededDescribe what is needed Introduce the EPEC-O curriculumIntroduce the EPEC-O curriculum
    29. 29. EE PP EE CC OO Trigger Video
    30. 30. Palliative Care Treatment to relieve pain and suffering.Treatment to relieve pain and suffering. May beMay be combinedcombined with therapies aimedwith therapies aimed at remitting or curing cancer, or it mayat remitting or curing cancer, or it may be the total focus of care.be the total focus of care.
    31. 31. Conventional Cancer Care PresentationPresentation DeathDeath Anti-neoplastic TherapyAnti-neoplastic Therapy BereavementBereavement CareCare 6m6m MedicareMedicare HospiceHospice BenefitBenefit
    32. 32. Comprehensive Cancer Care PresentationPresentation DeathDeath Anti-neoplastic TherapyAnti-neoplastic Therapy BereavementBereavement CareCare Symptom RxSymptom Rx Relieve SufferingRelieve Suffering Palliative Care 6m6m HospiceHospice CareCare
    33. 33. Gaps FearsFears Pain & SufferingPain & Suffering Be a burdenBe a burden Loss of controlLoss of control DesiresDesires Be comfortableBe comfortable Family able toFamily able to copecope Sense of controlSense of control Large gap between reality, desireLarge gap between reality, desire
    34. 34. 1998 ASCO Survey 6,645 oncologists surveyed6,645 oncologists surveyed 118 questions118 questions n = 3227 (48% response rate)n = 3227 (48% response rate) No significant differences inNo significant differences in answers based on oncologyanswers based on oncology specialtyspecialty
    35. 35. Source of Information about palliative care 90% Trial and Error90% Trial and Error 73% Colleagues and role models73% Colleagues and role models 38% Traumatic Experience38% Traumatic Experience Message: No one is teaching this toMessage: No one is teaching this to oncologistsoncologists
    36. 36. Inadequate education about palliative care 81% inadequate mentor or coaching81% inadequate mentor or coaching in how to discuss poor prognosisin how to discuss poor prognosis 65% inadequate information about65% inadequate information about controlling symptomscontrolling symptoms
    37. 37. Personal Failure 76% feel some sense of personal76% feel some sense of personal failure if patient dies of cancerfailure if patient dies of cancer 90% feel at least some anxiety90% feel at least some anxiety discussing poor prognosisdiscussing poor prognosis 75% feel at least some anxiety75% feel at least some anxiety discussing symptom control withdiscussing symptom control with patients and familiespatients and families
    38. 38. Unrealistic Expectations 29% Patient29% Patient 50% Family50% Family 27% Conflict27% Conflict
    39. 39. At least some Influence 97% Oncologists reluctant to ‘give up’97% Oncologists reluctant to ‘give up’ 99% Patient / family demands for99% Patient / family demands for antineoplastic therapyantineoplastic therapy 80% Chemotherapy is reimbursable80% Chemotherapy is reimbursable 80% Reluctance to talk about issues other80% Reluctance to talk about issues other than antineoplastic therapythan antineoplastic therapy 91% Takes more time to do palliative care91% Takes more time to do palliative care than give antineoplastic therapythan give antineoplastic therapy
    40. 40. Professional Satisfaction 98% some emotional satisfaction to98% some emotional satisfaction to provide palliative careprovide palliative care 92% some intellectual satisfaction to92% some intellectual satisfaction to provide palliative careprovide palliative care Marked contrast with preparationMarked contrast with preparation and a cause for optimismand a cause for optimism
    41. 41. Outline Describe the current state ofDescribe the current state of palliative care in cancerpalliative care in cancer Patients / familiesPatients / families OncologistsOncologists Describe what is neededDescribe what is needed Introduce the EPEC-O curriculumIntroduce the EPEC-O curriculum
    42. 42. Goals of EPEC-O Practicing oncologistsPracticing oncologists Core clinical skillsCore clinical skills ImproveImprove competence, confidencecompetence, confidence patient - physician relationshipspatient - physician relationships Patient / family satisfactionPatient / family satisfaction physician satisfactionphysician satisfaction Not intended to make everyNot intended to make every oncologist a palliative care expertoncologist a palliative care expert
    43. 43. EPEC-O Curriculum . . . conflict resolutionconflict resolution clinical trials – phase Iclinical trials – phase I preventing professional burnoutpreventing professional burnout goals of care, treatment prioritiesgoals of care, treatment priorities
    44. 44. EPEC-O Curriculum . . . symptom managementsymptom management diagnosis and prognosisdiagnosis and prognosis advance care planningadvance care planning cancer survivorshipcancer survivorship whole patient assessmentwhole patient assessment
    45. 45. EPEC-O Curriculum . . . physician-assisted suicide /physician-assisted suicide / euthanasiaeuthanasia withholding and withdrawing Rxwithholding and withdrawing Rx Hydration and NutritionHydration and Nutrition care in the last hours of lifecare in the last hours of life grief and bereavement supportgrief and bereavement support spiritual and cultural competencespiritual and cultural competence
    46. 46. EPEC-O Curriculum . . . how to teachhow to teach models of palliative caremodels of palliative care Next steps to improve palliative careNext steps to improve palliative care care in cancercare in cancer interdisciplinary teamworkinterdisciplinary teamwork (throughout)(throughout)
    47. 47. . . EPEC-O Curriculum apply each skill in your practiceapply each skill in your practice enhance professional satisfactionenhance professional satisfaction foster creative approaches to createfoster creative approaches to create change in cancer carechange in cancer care change will not be effective withoutchange will not be effective without oncologistsoncologists
    48. 48. EE PP EE CC OO SummarySummary Gaps need to be filled so thatGaps need to be filled so that palliative care becomes anpalliative care becomes an essential and inextricable partessential and inextricable part of comprehensive cancer careof comprehensive cancer care Plenary 1 EPEC for Oncologists Supported by the National Cancer Institute American Society for Clinical Oncology
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