IAN ANDERSON CONTINUING EDUCATION PROGRAM IN END-OF … · 2017-03-20 · Ian Anderson Continuing Education Program in End-of-Life Care University of Toronto Annual Report 2003-2004

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ANNUAL REPORT 2003-2004

www.cme.utoronto.ca/endoflife

___________________________________________________________________________ Ian Anderson Continuing Education Program in End-of-Life Care

University of Toronto Annual Report 2003-2004

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Laura Hawryluck MSc, MD, FRCPC Physician Leader, Ian Anderson Continuing Education Program in End-of-Life Care Assistant Professor, Critical Care, Department of Medicine University of Toronto Email: [email protected] Nancy Bush Program Coordinator Ian Anderson Continuing Education Program in End-of-Life Care University of Toronto Email: [email protected] 500 University Avenue, Suite 650 Toronto, Ontario M5G 1V7 Phone: 416-978-1837 Fax: 416-971-2723 Program e-mail: [email protected] Web site: www.cme.utoronto.ca/endoflife



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ANNUAL REPORT 2003-2004 IAN ANDERSON CONTINUING EDUCATION PROGRAM

IN END-OF-LIFE CARE UNIVERSITY OF TORONTO

The Ian Anderson Continuing Education Program in End-of-Life Care has completed the fourth year of its five-year cycle. We are pleased with the expansion of the program. This report will describe a number of the new endeavours. The activities of Physician Leader Laura Hawryluck, Program Coordinator Nancy Bush and Executive Board Members Kerry Bowman and Larry Librach have reached approximately 3,200 people this past year at events across the country. Our major activities in the last year were: 1. Teaching and program promotion 2. Development of relationships and links at local, provincial, national and international

levels 3. Surgery specialty initiatives 4. Development of new modules 5. Website expansion 6. Development of educational workshops and teaching video project with the Trillium

Gift of Life Network 7. Extensive work with standardized patients as a teaching tool 8. Development of a video on advance care planning 9. Collaboration with hospitals to develop quality assurance programs 10. Planning for future educational events 1. Teaching and program promotion The chart of activities at the end of this report will give a sense of the numerous activities undertaken by the Program principals to advance the cause of improved end-of-life care in this country. ! Opinion Leader Conferences # Southwestern Ontario/Ministry of Health and Long-Term Care Palliative

Care Teaching Initiatives

Two well-received opinion leader events were held in London, Ontario. The first was a two-day core content training event held May 30-31, 2003 for 34 physicians and nurses. On September 6, a one-day facilitator-training day taught educational methods and principles to 30 of these palliative care providers who are also involved in teaching.



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The Anderson Program worked with the seven Pain and Symptom Management Network coordinators for this very large region to develop a training program to meet their Ministry of Health and Long-Term Care palliative care education initiatives. The new Comprehensive Advanced Palliative Care Education (CAPCE) program for regulated health care professionals developed by the coordinators focuses on the development of Hospice Palliative Care Resource Professionals in facilities, agencies and communities throughout the Southwest. The educational events that resulted from this program are: Please see the attached report from the CAPCE program coordinators on the results of the 2003-2004 sessions at the end of this document.

# Cobourg, Ontario After hearing Laura Hawryluck speak at the International Interdisciplinary Wound Care Course, Karen Bruton, a registered nurse who organizes educational programs in the region, approached the Ian Anderson Program to present a core content day to local physicians, nurses and other healthcare providers. 50 people from as far east as Belleville gathered together to participate in a workshop taught by Russell Goldman and Mary van Soeren, covering four modules chosen by local needs assessment. Evaluations for the day were excellent and we would like to thank Karen Bruton for inviting us to present the program in the region.

# Owen Sound, Ontario As part of the overall initiative for end-of-life care education in southwestern Ontario, Marie Palmer, the Pain and Symptom Management Coordinator for Owen Sound, arranged for Dr. Hawryluck to teach at a number of events in the region April 10-11, 2003. Due to SARS this had to be re-scheduled October and started with an evening presentation on demands and rights to treatment, consent and ethics and the law. On the following day Dr. Hawryluck facilitated a two-hour teaching session with local nurses followed by an hour-long Grand Rounds for physicians and multidisciplinary group of professionals

! Conference Exhibits

The Anderson Program continued expanding its audience by exhibiting at the national conference of the Canadian Hospice Palliative Care Association in Quebec City in June of 2003. Locally, display tables were taken at the November 2003 Pain & Symptom Management Conference and the Pediatric Oncology Group of Ontario meeting and the April 2004 14th Annual Provincial Conference on Palliative and End-of-Life Care. It is clear that the Anderson Program is becoming familiar to the palliative care community as more and more people are approaching staff in the booths to offer praise, suggestions and to ask after additional modules.



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! Media Coverage # In April 2004 Dr. Hawryluck was asked by the Medical Post to comment on a

recent study out of the University of Pittsburgh, published in the journal Critical Care Medicine, that found that more than one in five Americans will die in the ICU. She stressed that more communication is necessary to help patients and families understand options and end-of-life decision-making.

# Laura Hawryluck continues to be a media contact for the University of Toronto

and the Royal College of Physicians and Surgeons of Canada on end-of-life care.

2. Development of Relationships and Links at Local, Provincial and

National Levels

Below are some highlights of our relationship building in the fourth year of the program. Please refer to the activities chart for a complete list of events.

LOCAL: ! Laura Hawryluck, Larry Librach, the W. Gifford-Jones Professor in Pain Control and

Palliative Care at U of T and the director of the Temmy Latner Centre for Palliative Care at Mount Sinai Hospital, and Dr. Alex Jadad, the Rose Family Chair in Supportive Care and director of the Program in eHealth Innovation at the University of Toronto, continue to work on establishing the Latner Centre for Research in Palliative Care, a cross-institutional centre of excellence in supportive/palliative/end-of-life care. Plans continue to advance for the centre�s inception and development with a firm commitment from Mt. Sinai to provide physical space. Work will commence on the centre in September 2004 with over 5,000 sq.ft. dedicated to research, education and administrative offices with state-of-the-art videoconferencing facilities.

! A multidisciplinary team, (composed of physicians, nurses, social workers and

bioethicists) headed by Dr. Gary Rodin and including Laura Hawryluck, collaborated on writing a CIHR proposal for a New Emerging Team in End-of-Life Care. The grant would provide the funding for the infrastructure to support a research group in end of life care across disciplines. A decision for the proposal is pending.

! University of Toronto Faculty of Medicine Teaching

Some highlights of the University of Toronto teaching schedule were: # CRISP Ethics Seminars � Topics included Capacity, Consent, and End-of-life

Decision-Making



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# St. Michael�s Hospital End-of-Life Quality Improvement Committee case presentation on ethics and the law at the end of life

# Toronto East General Family Practice Residents � workshop on �Practical Issues of End-of-Life Decision-Making�

# Science and Art of Pain and Symptom Management Annual Conference debate with Dr. Scott Berry � For research purposes, palliative care patients should be treated as a �vulnerable population�

# St. Michael�s Hospital Medical Grand Rounds � �Who�s got the power? Dealing with demands for treatment�

# University Health Network Psychiatry Grand Rounds � Presentation on ethics and law of consent and capacity

# University Health Network �Toronto General Grand Rounds: �Why can�t we agree?� a presentation on demands for treatment

# University Health Network, Toronto Western Hospital � � Why Can�t We Agree?� � a presentation on demands for treatment with Mr. Mark Handelman, Vice-Chair of the Consent and Capacity Board of the Province of Ontario

# University Health Network � Toronto Western Hospital and Toronto General Hospital MSICUs � Ethical Issues in Critical Care

# University of Toronto, ICU Fellowship Program: �Ethical and Legal issues in Demands for Treatment�a case study� with Mr. Mark Handelman, Vice-Chair, Consent and Capacity Board, Province of Ontario

# University of Toronto, Nurse Practitioner Program: 1½ days on Legal and Ethical Issues for Nurse Practitioners. Topics included End-of-Life Decision-Making and Capacity (Mr. Mark Handelman), Legal Issues in Geriatrics (Ms Judith Wahl, Advocacy Centre for the Elderly), Conflict Resolution at the End of Life (Dr. Kerry Bowman), Mental Health Law and Decision-Making (Mr. Nils Riis, Psychiatric Patient Advocacy Office)

# University of Toronto nurse practitioner program Spring Residency Program two-day event � workshops on Pain and Symptom Management, Ethics and Law, and Approaching End-of-Life Discussions

! Toronto Western Hospital, Neurosciences Program

Shelley Hynes, an ICU nurse and Clinical Educator of the Neurosciences Program at Toronto Western Hospital, as well as being one of the on call coordinators for the Trillium Gift of Life Network (TGLN), contacted us early in 2004 about using information from the Ian Anderson Program in a program whose goal is to improve the communication between nurses and family members. She intends to approach this from a bedside nursing aspect and address the more common scenarios and questions nurses are faced with when supporting family members. She also plans a focus on the communications piece the Anderson Program developed with the TGLN, particularly those aspects dealing with anger/disbelief and common mistakes to avoid when speaking with family members. Ms Hynes will present papers at the University Health Network nursing forum in May and the annual conference of the Canadian Association of Neuroscience Nurses in Calgary in June of 2004.



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! McMaster University Medicine Academic Day

Laura Hawryluck was invited to give two talks to this group of McMaster University School of Medicine physicians and residents: The Ethics of SARS, and Assisted Death/Double Effect. Approximately 100 staff and residents attended this full-day event in Hamilton on April 7, 2004. Evaluations were excellent and McMaster has expressed interest in having Laura return next academic year.

! Scarborough CCAC Palliative Care

The Anderson Program was invited to present at the Scarborough CCAC Palliative Care Grand Rounds on �Conversations at End of Life: decision-making and futility�. These monthly two-hour rounds draw approximately 100 people from the local palliative care community. Laura Hawryluck had one of the highest attendance rates for both her sessions. She met with people after the reception and spoke to them one-on-one about their concerns. The talk was so successful Dr. Hawryluck was invited back to speak in May and the fall of 2004.

PROVINCIAL: ! Ontario Seniors� Secretariat

Our partnership with the Seniors� Secretariat of the Ontario Ministry of Citizenship, under Ontario's Strategy for Alzheimer Disease and Related Dementias, to co-sponsor opinion leader workshops for family physicians and specialists in Ontario over a two-year period, ended in 2003. �Collaboration, Working Together, Partnerships�, a five-year review of the work of the Secretariat published in 2004 acknowledged the contribution of Laura Hawryluck and the Ian Anderson Program to its education initiatives on advance care planning.

! University of Toronto/Ministry of Health and Long-Term Care Palliative Care

Course An exciting new collaboration, begun in the fall of 2002, with the U of T/MOHLTC palliative care course offered to family physicians in Toronto and York and Simcoe Counties under the Ministry Palliative Care Initiative II plans, continued into 2003-2004. The Anderson Program collaborated with course staff in development of a revamped program that will include a strong online component as well as videoconferences. As part of this we will expand our use of standardized patient s and families by developing new scenarios. A link will be available from the Anderson Program website. The Anderson Program will also help to fund the evaluation mechanism for the re-designed course.



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! Associated Medical Services Partnership # AMS-COFM 5th Annual Conference � November 6-7, 2003

Each year for the last four years AMS has provided $25,000 in funding to an Ontario medical school to hold a conference on issues of concern to the Council of Ontario Faculties of Medicine (COFM). 2003 was the University of Toronto�s turn to host the conference and the Office of Continuing Education was asked to take on the organization.

Dr. Bill Seidelman, president of AMS, in discussions with Laura Hawryluck and Dr. Dave Davis, associate dean of continuing education, expressed particular interest in focusing on increasing end-of-life care education at all levels in Canadian Medical Schools. The conference brought together a core group of 50 educators and administrators from medical schools across the province for 1½ days. Dr. David Weissman, project director of the American program, End of Life/Palliative Education Resource Center and director of the Palliative Care Program for the Medical College of Wisconsin, gave the opening plenary. A number of poster abstracts were reviewed and several chosen for display at the conference.

Presentations were held on current data, barriers, use of standardized patients and online learning, research and evaluation and creative solutions and collaboration to effect change. At the end of the conference a core group formed to move forward the cause of education in end-of-life care at all levels.

# AMS Research Project

Associated Medical Services has approved $5,000 in funding for a research project that will unite palliative care, internal medicine and intensive care in a multiprofessional, multidisciplinary way that has never been done before. It will focus on quality of care and quality of life for those nearing the end of life to be conducted by Laura Hawryluck, Dr. Maria Bacchus, Dr. Neil Lazar, Dr. John Granton, Ms Janice Wright and Dr. Dave Davis. The goals of this pilot project are: 1. To explore different professional perspectives on the challenges in and barriers

to providing quality end-of-life care on a general internal medicine ward 2. To develop a multidisciplinary/multiprofessional model of change, a series of

creative solutions to improve knowledge, attitudes and skills in caring for dying patients and their families through faculty development, quality of life rounds and advance care planning seminars for patients and families

The project was delayed due to SARS. It was submitted and approved by the research ethics board of the University Health Network. Unfortunately, we were unable to get the project off the ground, despite massive efforts. While there was a lot of initial enthusiasm, at the time of implementation it was difficult to obtain participants. After investigating reasons for this, the best we could determine was



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that the resistance was due to perception from the Ward staff that it was originating in the ICU and due to concerns regarding the workload involved. Currently the project has been tabled pending the appointment of the AMS Fellow in End-of-Life Care who, based on the Internal Medicine Ward, may have more success in running the project. In the meantime, spin-off proposals to develop ways of improving decision-making through patient and family education are being developed by Drs. Lazar, Hawryluck and Nusdorfer.

! Ontario College of Family Physicians

Laura Hawryluck and Larry Librach each facilitated one-day workshops with Judith Wahl, LLB, for the Ontario College of Family Physicians Advance Care Planning Physician Training Program, Dr. Librach in Toronto, Dr. Hawryluck in London. The Programs, four in total, reached all areas of the Province and used material �the end of life decision-making module--developed by the Ian Anderson Program.

! 10TH Annual Conference: The Science & Art of Pain and Symptom

Management

Anderson Program faculty again participated in this conference held November 14-15, 2003. Laura Hawryluck debated with Dr. Scott Berry �For research purposes, palliative care patients should be treated as a �vulnerable population��. This debate was so well received that Drs. Berry and Hawryluck were asked to prepare an article for the Journal of Clinical Oncology, published by the Royal College of Radiologists in February of 2004. Larry Librach conducted a workshop on Managing the Patient with Complex Pain. Russell Goldman, Anderson Program faculty member, is the organizer of this annual conference in alternate years.

! Nurse Practitioner Programs

Through Mary van Soeren, Assistant Professor, Director of Nurse Practitioner Programs at the University of Toronto and an Anderson Program faculty member, the Anderson Program has taken a role in nurse practitioner program development. # Laura Hawryluck worked with Dr. van Soeren on a workshop on end-of-life

decision-making and futility for the Registered Nurses Association of Ontario Annual Nurse Practitioner Conference: Celebrating 30 Years of Practice. Approximately 90 NPs attended the two presentations of the workshop.

# Drs. Hawryluck and van Soeren also developed a two-day program on medical

ethics and law for the University of Toronto Nurse Practitioner Spring Residency Program. Approximately 30 experienced nurses enrolled in the NP program participated in this event that focused on conflict at the end of life and the legal issues of consent and capacity, substitute decision-makers, elder abuse and



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nursing home care, and culture and family conflict. Laura Hawryluck gave a clinical context to the program as well as the physician perspective. Judith Wahl, from the Advocacy Centre for the Elderly and author of the legal section of the Anderson Program module on decision-making and Kerry Bowman, author of the Culture and Conflict Resolution modules, both presented at the workshop. As faculty for this special, new program, they were joined by Mr M. Handelman, Vice Chair of the Consent and Capacity Board of Ontario, and Mr. N. Riis, legal counsel from the Psychiatric Patient Advocacy Office.

# Confederation College in Thunder Bay offers a 300-hour post RN certificate

program in Oncology Nursing, which includes a palliative care course. Some of the students participate by distance education audio conference learning from several locations in Northwestern Ontario through the Contact North distance education agency. The Anderson Program was approached by the College to use our modules and slide presentations as resource materials in the palliative care class.

! Quinte Healthcare DNR Conference

Dr. Graham Burke, co-chair of the Bioethics Committee of Quinte Healthcare Corporation, approached Laura Hawryluck to participate in a two-day hospital/community workshop on DNR held in September of 2003 in Belleville. In addition to QHC, which includes the hospitals at Belleville, Trenton, Bancroft and Picton, other organizations participating included the Community Care Access Centre, local group homes for the developmentally challenged, nursing homes and other "stakeholders" from the community and Queen�s University representatives. During the half-day workshop, Dr. Hawryluck spoke to 100 registrants on �CPR: The past, the present and the controversies�, and on �Demands for Treatment�, with a focus on decision-making regarding life-sustaining interventions. This half-day workshop was designed to facilitate the implementation of a new hospital policy on resuscitation at Quinte Healthcare. Participants came from as far away as Brockville, and included the Dean of Continuing Education at Kingston�s Queen�s University medical school. Evaluations for the half-day were excellent and we have been invited to participate at future events being planned in the region.

! Thunder Bay, Ontario

The Thunder Bay Medical Society CME committee invited Laura Hawryluck to speak at its annual conference in September on "The Quest for the One Ring: Patients demands and rights to treatment". Dr. Hawryluck was also asked to speak about the Anderson Program at the end of the talk to introduce the program to those physicians who were not aware of what we have to offer.



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! 14th Annual Provincial Conference on Palliative and End-of-Life Care, Toronto

Laura Hawryluck and Kerry Knickle was asked to present a standardized patient (family) workshop at this annual conference, held April 25-27, 2004. 40 Multidisciplinary registrants attended two extremely well received presentations of the workshop, Communication in the Doctor-Patient Relationship: "Pathological Denial".

NATIONAL: ! Educating Future Physicians in Palliative and End-of-Life Care (EFPPEC)

Larry Librach has been designated physician leader member of the management committee of the EFPPEC project. This project is a direct result of the work of the Senate Steering Committee on End-of-Life Care, of which Dr. Librach and Laura Hawryluck were members. The project is co-facilitated by the Association of Canadian Medical Colleges (ACMC) and the Canadian Hospice Palliative Care Association (CHPCA). The management committee was structured to partner those involved in end-of-life care and education with those involved in providing education in undergraduate and postgraduate medicine and includes representatives from several universities, ACMC, CHPCA and Health Canada, with Dr. Alan Neville of McMaster University as chair. The project goal is that by the year 2008, all undergraduate medical students and clinical postgraduate trainees at Canada�s seventeen medical schools will receive education in palliative and end-of-life care so they will graduate with competencies in these areas. Teams will form at each of the medical schools. Its objectives are to: # Develop consensus-based palliative and end-of-life care common competencies

for undergraduate trainees in medicine and for postgraduate trainees in key clinical specialties (e.g., internal medicine, paediatrics, surgery, medical and radiation oncology, family medicine, critical care, emergency care, etc.)

# Establish a national project team to act as a resource to support palliative and and-of-life care education across the country

# Develop an interdisciplinary team (from various disciplines and specialties) at each university to identify the gaps and opportunities related to palliative and end-of-life care (at their university), develop a strategy to address the gaps and implement the strategy.

# Empower faculty in the various specialties to become palliative and end-of-life care mentors.

# Facilitate the introduction of curriculum based on core competencies for all undergraduate and clinical postgraduate trainees at each medical school.

# Encourage the introduction of palliative and end-of-life care questions in licensing and certification exams.



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# Stimulate the development of interdisciplinary palliative and end-of-life care.

Approaches used in each university will reflect unique needs and circumstances. The project overview was presented by Dr. Librach and Dr. José Pereira, University of Calgary, to the annual meeting of the ACMC in Halifax on April 24, 2004, and was well received.

! Royal College of Physicians and Surgeons of Canada

Dr. Michel Brazeau, chief executive officer of the Royal College of Physicians and Surgeons of Canada has always expressed great interest in improving end-of-life care in Canada. This year, the Royal College developed educational objectives outlining core competencies in end of life care to be met by all subspecialty programs. Dr. Hawryluck was asked to review these objectives and suggested modifications that were accepted near verbatim by the Royal College. The Royal College will continue to work with the Anderson program and EFPPEC to ensure these new educational objectives are achieved. Plans are underway to include questions dealing with end of life issues on the fellowship exams. Laura, in collaboration with Dr. Alexandra Easson (Surgical Oncology, U of T), has already developed Royal College exam questions for General Surgery exams and they have received confirmation that these questions will be used. In the past years, Laura has also developed questions for Internal Medicine exams. As well, the Critical Care Program has just been given permission to set National Royal College exams and Laura will be developing questions/stations focusing on end-of-life issues for this group in the future.

! Specialty group events # At the annual conference of the Royal College of Physicians and Surgeons

of Canada, Laura Hawryluck and Drs. Alexandra Easson and Lorne Rotstein from the Department of Surgery at the University of Toronto presented a session on �Bringing back humanism to enhance professionalism in residency education.� The audience consisted of physician program directors and heads of departments with a focus on the need for humanism and implications for professionalism (the theme of the conference) in the care of patients at the end of life. The presenters discussed methods of educating and evaluating residents as they learn skills for managing palliative patients and sources of information, such as the Anderson Program and EPERC/EPEC in the United States.

# University of Manitoba Internal Medicine and Critical Care Training

Programs: In June of 2003 Laura Hawryluck, Mary van Soeren and Dianne Longboat, author of the module �Indigenous Perspectives on Death and Dying�, went to Winnipeg for a three-day program.



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Dr. Hawryluck went to Winnipeg a day in advance to train standardized families (in scenarios she has developed), from the University of Manitoba Standardized Patient Program. The three- day program, using standardized families, taught critical care fellowship trainees how to communicate, facilitate decision-making and address common ethical, legal and cultural issues that arise in practice.

Dr. Hawryluck also presented at Internal Medicine Grand Rounds on �Futility and Demands for Treatment�. She presented evening multidisciplinary Critical Care rounds on pitfalls of decision-making regarding life-sustaining interventions.

Drs. Hawryluck, vanSoeren and Longboat then taught both Internal Medicine resident and the Critical Care fellows in a day long event. Topics included decision-making, inter-professional responsibilities and teamwork, culture and conflict. Dianne Longboat spoke about indigenous culture and how to address end-of-life in the hospital setting.

! Small Group Programs

Small group programs are ongoing or have begun in several regions: # Dr. Janice Mulder continues to run regular events for physicians in Manitoba # Dr. Mervyn Dean remains dedicated to advancing care of the dying in

Newfoundland, running five teaching sessions for multidisciplinary participants in Corner Brook, Port-aux-Basques and Stephenville, in the spring and fall of 2003, using five of the modules. Evaluations from participants were excellent.

# Dr. Charlie Chen, a palliative care physician in the Fraser Health Authority of Lower Mainland, British Columbia (suburbs of Vancouver), organized a two-day event in March of palliative education for family physicians interested in upgrading their skills and knowledge in palliative care. He reports that 25 physicians registered for the event. All attended the modules for Pain Management in the morning of the first day and Symptom Management in the afternoon � divided into four groups. On the second day, registrants chose between two of four modules: Communications, End-of-Life Decision Making, The Last Hours, and Psychological Symptoms � one each in the morning and afternoon.

# Drs. Robert Sauls and Paul Zeni taught a number of modules over the fall of 2003 and winter of 2004 as part of the Halton-Peel Ontario Ministry of Health and Long-Term Care palliative care teaching initiatives. A total of 20 family physicians registered for five modules held in Mississauga and Georgetown.

# Sonja Habjan, HBSW, MA, Palliative Care Education Coordinator for the Northern Educational Centre for Aging and Health at Lakehead University, presented the �Last Hours� module to a group of 12 RNs at its Palliative Care for Community Nurses workshop in April of 2004. Ms Habjan was also responsible for inviting Dr. Hawryluck to the Thunder Bay CME Committee conference in September (see Provincial Events, above).



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# Dr. Nancy Merrow taught a session in the York Region of Ontario on use of �Build a case� as a teaching tool

# Lynda Weaver, Research Associate at the University of Ottawa Institute of Palliative Care, reports that they continue to include Anderson Program modules in all Initiative II teaching in Ottawa and Renfrew County and hope to offer them in the Five Eastern Counties as well.

# Dr. Romayne Gallagher presented the Symptom Management module to a group of physicians and nurses in Vancouver

# Kim Stafaniuk, a pharmacist at Princess Margaret Hospital has facilitated a number of sessions using Anderson Program modules for pharmacists as they learn about palliative care, a new service for the hospital. She and her colleagues presented a poster about the education initiatives to the International Society of Oncology Pharmacy Practitioners symposium in April 2004 in Turin, Italy. The poster highlighted the Anderson Program modules and directed delegates to the website.

! Manitoba Law Reform Commission

The Manitoba Law Reform Commission invited Laura Hawryluck to be a member of the review committee for its position paper on withholding/withdrawing life-sustaining interventions. This document is to be used in forming law and fundamental principles and policies around demands for treatment and conflicts within medicine. It contains the commission�s recommendations for implementing that protocol and will have a national impact. The position paper is now out in print and on the Commission website with acknowledgement given to the Anderson Program for its contribution.

! Canadian Paediatric Society

Dr. Peter Farran presented at the annual meeting of the Canadian Paediatric Society in June 2003 on what paediatricians can offer when caring for palliative patients. The Anderson Program was highlighted as a key resource for information. Dr. Farran is on the review committee for the new module, �Decision-Making in Pediatric Palliative Care.�

INTERNATIONAL ! IV International Symposium on Coma and Death, Havana, Cuba

Laura Hawryluck was invited to present at the IV International Symposium on Coma and Death. She and Kerry Knickle and Laura Jane Nelles of the Standardized Patient Program demonstrated the use of Standardized families in a workshop entitled �Brain death and organ donation: teaching communication skills�. The Trillium Gift of Life Network scenarios formed the basis for the content of this workshop attended by 30 healthcare professionals. The workshop was so successful



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participants from Cuba asked to have a copy of the teaching materials so that they could use them to teach with in the future.

! 11th International Ottawa Conference on Medical Education Dr. Hawryluck submitted an abstract to the to be held in Barcelona, Spain, July 4-8, 2004, for a workshop on Education of Ethics and Ethics of Education. The abstract was accepted.

! Joint Centre for Bioethics MHSc Program

As part of the Joint Centre for Bioethics� international outreach Laura Hawryluck lectured to students from the Masters in Health Science Program on End-of-Life Care in Canada and the Ian Anderson Program. The Masters in Health Science is an international program with graduate students from multidisciplinary healthcare fields, who enroll at U of T to obtain a Masters in Ethics degree. Graduates will bring their training home and use it in their own countries.

! Toronto Critical Care Medicine Symposium

Laura Hawryluck was closely involved with planning of the 2003 annual international Toronto Critical Care Medicine conference as well as presenting two workshops: End-of-Life Ethics in the ICU, with Drs. Mary van Soeren, Jean Louis Vincent and Graeme Rocker; and a second workshop with the Trillium Gift of Life Network on the organ and tissue donation education program (see 6, below).

3. Surgery Specialty Initiatives

# Dr. Alexandra Easson, with the strong support of Dr. Lorne Rotstein the General

Surgery Program Director, has been key in promoting end of life care within the surgical program. The Anderson Program has been extremely fortunate in having increased its collaboration this year with both of them. They are innovators with whom it is a real pleasure to work.

# Dr. Alexandra Easson was asked to create an educational video and module on

disclosing medical error and dealing with end of life issues by the Task Force on Surgical Palliative Care and the Task Force on Interpersonal and Communication Skills of the Division of Education at the American College of Surgery. The University of Toronto is the only Canadian University within the American College of Surgery and this honour bespeaks the acknowledgement of her skill, her enthusiasm and her vision for change. She invited Dr. Hawryluck and the Anderson Program to help her in this exciting and important endeavour. This project is currently going very well and much more detail will be provided in next year�s annual report. The Anderson program will gain considerable international exposure from this collaboration. The budget for the proposal is $14,000 � applied for and granted by the American College of Surgery.



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# Drs. Easson and Hawryluck applied for and were awarded a $10,000 Dean�s

Excellence Fund grant to use the ACS video and material to teach surgical residents communication skills, ethics and law and to evaluate its effectiveness as a teaching tool. As part of the proposal, they will work with Dr. Lorne Rotstein to create an OSCE exam for all general surgery trainees to assess their communication skills, their ability to facilitate decision-making, to care for patients and the end of their lives. The funds for the project and matched by the Department of Surgery.

# Drs. Easson, Rotstein and Hawryluck will be developing the OSCE exam over

the next few months. The exam will use standardized families and patients. Plans are to run the OSCE in early winter. Much more detail regarding the arms of this project will be available next year.

# The Anderson Program is pleased to congratulate Dr. Alexandra Easson who

has just been awarded the only AMS Fellowship in End of Life Care in Surgery in Canada. As the AMS Fellow she will serve as a role model to improve the quality of end of care for surgical patients at the University of Toronto and nationally. The surgical fellowship came to be created partly due to negotiations by the Anderson Program with AMS. This Fellowship is modeled on a similar one in Internal Medicine and makes the University Health Network the only centre in the province to have chairs in both disciplines.. The Anderson Program will be very pleased to continue its support of all her Dr. Easson�s efforts and help her as needed.

4. Development of new modules # Pediatric Module on Decision-Making at the End of Life. After final edits are

complete, the eagerly anticipated first paediatric module will be on the Anderson Program website in June of 2004. Dr. Gerri Frager of Dalhousie University and Yarrow McConnell, Dalhousie Class of 2005, have written the module, �Decision-Making in Pediatric Palliative Care, with the input of an extensive advisory group of Canadian and American physicians, nurses, social workers and clergy. This module involves all aspects of decision-making at the end of a child�s life, from the perspective of the child, the family and the healthcare providers involved. A slide presentation of the module will be created by Drs. Frager and McConnell. Dr. Hawryluck has written pre- and post-tests and the Anderson Program will ensure it receives Mainpro-C accreditation by the College of Family Physicians of Canada as all other program modules have before it.

The authors also used the module in writing chapters in �The Textbook of Paediatric Palliative Care� and �The Textbook of Palliative Medicine � A Case Based Manual�. This will expand the program�s international exposure.



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# Grief and Bereavement: Larry Librach is revising the new module on grief and bereavement, following a peer review of the first draft. Written with Pauline Abrahams, the module will address this sensitive subject to help healthcare professionals deal with patient and family grief. Draft copies of the module displayed at conference exhibit booths in the past year have been received with enthusiasm. It will be on the website with its slide presentation by the end of summer. Again Dr Hawryluck will write pre and post-tests to ensure Mainpro-C accreditation.

# Organ and Tissue Donation: Dr Hawryluck has modified the PowerPoint

teaching tools she developed for the Trillium Gift of Life Network Project (see below). These slides will provide guidance to all healthcare providers on how to explain neurological death and facilitate communication and decision-making regarding organ and tissue donation. More information and help can be obtained from the Trillium Gift of Life Network and links to this site are now available on the Anderson Program website.

5. Website expansion

The web site continues to very popular. Between May 1, 2003 and April 30, 2004 there were 32,148 visits to the pages of the Anderson Program site. A page on the organ donation education program developed with the Trillium Gift of Life Network (see below) will be on the website in June 2004 as will the new pediatric decision-making module. Visitors to conference exhibit booths continue to praise the site and say they use it on a regular basis. Several nurses writing the first round of the CNA exams reported that they used the materials to study for the exams. The site was recently re-designed to a cleaner format but remains simple and easily accessible for those with older computers.

6. Development of educational workshops and teaching videos with the Trillium Gift of Life Network As reported in 2003, the Trillium Gift of Life Network (TGLN) had approached the Anderson Program in late 2002 about collaborating on an exciting and innovative venture to teach the professional staff of the Trillium Gift of Life Network across the Province of Ontario the end-of-life decision-making, ethics and legal standards surrounding organ and tissue donation and the skills needed to communicate with the families and loved ones of brain dead patients. The TGLN's mission statement informed program development: "To enable every Ontario resident to make an informed decision to donate organs and tissue, and to support healthcare professionals in implementing their wishes. To maximize organ and tissue donation in Ontario in a respectful and equitable manner through education, research, services and support." Three modules and 11 standardized family scenarios (10 in



18

English and one in French) were developed in collaboration with Kerry Knickle, Head of Special Projects of the University�s Standardized Patient Program. In the summer and fall of 2003 five videos were produced and are now available through the TGLN. Nine scenarios developed for SPs are used to provide hands-on small group teaching and feedback during 1½-day workshops for new organ donor coordinators across the province. Topics include improving communication skills to explain neurological death, facilitate decision-making regarding organ and tissue donation, and address common ethical and legal dilemmas at the end of life. All have received �rave reviews.� And have been used repeatedly to teach new TGLN staff, physicians and allied healthcare workers locally, nationally and internationally. The Anderson Program also promotes the program as essential basic knowledge for all healthcare professionals with a special page on its website. At the annual 2003 Toronto Critical Care Medicine Conference Laura Hawryluck, Kerry Knickle and Lucie Forget of the TGLN introduced the program to specialists in a well- received workshop entitled �Communicating about brain death and organ donation: the state of the art.�

7. Extensive work with standardized patients as a teaching tool

The Anderson Program and Laura Hawryluck have been using standardized patients as a teaching tool for a number of years. However, the need for programs to teach communications around end-of-life care and the more difficult aspects of ethics and law is clearly escalating. Recognizing that patients are members of sometime extensive families, that families serve important roles in providing care and support and that family members are often substitute decision-makers in the event of incapacity means that healthcare providers� communication skills need to extend to speaking with families as well as individual patients. Such a need adds complexity to end of life care as different family members have different emotional, psychological, informational and spiritual needs � all of which need to be addressed simultaneously. As well conflict may arise � in fact does so commonly � between family members, family members and patients and the healthcare team. Such conflicts can have significant impact on the care and decision-making with dying patients. These skills however, have not been taught to date. To address this gap we have worked on a number of projects and events that employ this new innovative tool, the standardized family to provide the needed depth and complexity of real life situations. The Standardized Patient Program at the University of Toronto is an excellent partner in our efforts, with innovative and creative staff. Projects have had Laura Hawryluck writing the scenarios, creating teaching materials and training actors with Ms Knickle�s invaluable assistance. We have used standardized families on several projects in the few years (see past reports for lists of activities involving



19

standardized families in Ottawa and Toronto) and have expanded even further in the last year and plan to expand it even further in the next year:

# TGLN educational project (see 6. above) # Anderson Program Conference, Winnipeg, June 4-6, 2003 (see Specialty Group

Events above) # Surgery Projects # Toronto Critical Care Medicine Symposium # IV International Symposium on Coma and Death, Havana, Cuba, March 9-12,

2004 (see International above) # 14th Annual Provincial Conference on Palliative and End-of-Life Care, April 25-

27, 2004. A well-attended 1½-hour workshop � Communication in the Doctor-Patient Relationship: "Pathological Denial� � was presented twice at the conference to enthusiastic participant response.

8. Development of a video on advance care planning

The Anderson Program is in the initial stages of development of videos on advance care planning to facilitate informed decision-making at the end of life.

In the past century rapid advances have occurred in our understanding of severe illnesses followed by rapid technological and therapeutic advances in medicine in general and in critical care in particular. Now at the start of the new millennium, life can be sustained and prolonged where it would have been impossible to do so a few short years before. Buoyed by these successes, we have unfortunately lagged behind in helping society, patients and their families decide if and when these tools should be used in the context of our individual and collective goals, values and beliefs. We have therefore seen as an unintended side effect of our modern technological advances, the potential to maintain people in a state of suspended animation for prolonged and, on occasion, indefinite periods hoping for a long shot cure.

This capacity to sustain the lives of critically ill people, has given rise to very important questions that we must all eventually confront as individuals and as members of a multicultural society. Most of these questions centre around one fundamental dilemma: just because we have the capacity to prolong life, does this mean we should? Concepts and notions of dignity, of suffering, of benefits and burdens and ultimately of quality of life come into play and have been hotly debated. Fears of being kept alive on machines have surfaced and have led to a public search for a voice in healthcare decision-making to a previously unprecedented extent. The goal of the project is to develop two innovative educational videos: # For healthcare providers � Using standardized families



20

To teach healthcare providers the necessary communication skills to facilitate advance care planning meeting current Canadian ethical and legal standards

# For the Canadian public and their lawyers �

To ensure advance care planning decisions by patients and their substitutes are informed by describing 1) what decisions they will/may face, 2) what the choices and treatments entail, 3) the different contexts in which they may be needed and 4) the benefits, burdens and alternatives to such therapies.

These videos could be placed in physicians� and lawyers� offices and serve as innovative and powerful tools to facilitate decision-making, ensure everyone is more informed and yet save time by providing baseline information and allowing patients and clients to generate questions and thoughts regarding advance care planning prior to meeting with their physician and/or lawyer or substitute decision-makers. As such the video will potentially have a very large impact on the Canadian public and ensure these difficult decisions regarding therapeutic interventions at the end of life are better informed and well reasoned. The Anderson Program has applied to several sources for matching funding for this project.

9. Collaboration with hospitals to develop quality assurance

programs The Anderson Program was approached by a number of hospitals to consult in the creation of hospital-wide quality assurance programs to improve the communication skills of staff members and residents around end-of-life care and advance care planning. # Doreen Ouellet, a registered nurse and clinical bioethicist at Toronto East

General Hospital, contacted Laura Hawryluck in June of 2003 for recommendations in setting up a program for its staff and help in determining what supports need to be in place to assist physicians when faced with end-of-life decisions. Ms Ouellet wrote that �like many other acute care centers, there is a need for end-of-life care, not only with our palliative care patients, but also and maybe just as much in our intensive care units.� Dr. Hawryluck met with Ms Ouellet and Alfio Meschino, Chief of Staff and, as a result, ten of the Anderson Program modules were facilitated as a pilot for groups of up to 31 nurses, social workers and other hospital healthcare providers over the course of six months, to end in June of 2004. Plans are being made to extend the program to physicians in the fall.

# Staff from the Princess Margaret Hospital contacted the Anderson Program

regarding setting up a quality assurance program for end-of-life care. The group,



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headed by Dr. Jeremy Sturgeon, is currently considering the best approach for such a program.

# Dr. David Levine, nephrologist at The Ottawa Hospital � Riverside, also

approached the Anderson Program about a similar program at that facility. 10. Planning for future educational events ! In the next year Dr. Hawryluck plans to continue to expand on her extensive work

with standardized patients and families to teach specialists ! The Anderson Program will be working with the General Surgery Program at the

University of Toronto to create an OSCE exam which hopefully will be a model for other centres across the Country and internationally

! The Advance Care Planning Video for Healthcare providers will also use

standardized families and again will hopefully serve as a valuable resource for others.

! The Critical Care Fellowship Program will be developing some standardized

family scenarios as teaching tool for their ICU fellows to address communication and decision-making at the end of life

! We will also continue to support our Opinion Leader s to develop educational

events that will suit their needs. ! In June Dr. Hawryluck will present two workshops at the 11th International Ottawa

Conference on Medical Education

# Standardized Families: Bringing to Life the Depth and Complexities in End of Life Care, with Kerry Knickle of the University�s Standardized Patient Program. The workshop will provide a live demonstration of the SF as a teaching tool and discuss how to develop scenarios and train SF. The audience will be international and provide considerable exposure for the Anderson Program

# Education of Ethics and Ethics of Education with Dr. Madelena Patricio from

Spain. International panel workshop discussing how to teach ethics, and professionalism. Again it will provide considerable exposure to the Anderson Program.

! Laura Hawryluck is on the steering committee of the November 2003 Toronto

Critical Care meeting, a conference attended by several hundred critical care healthcare workers across the country and internationally. In the coming year she will be organizing a Medical Legal session around end-of-life issues.



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! Dr. Hawryluck will also explore and expand the hospital-based quality improvement initiatives in end-of-life care.

! Dr.Hawryluck is also exploring teaching our legal colleagues about the

complexities of end-of-life care in order that they can provide better guidance for their clients nearing the end of life.



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CONCLUSION The fourth year of the Ian Anderson Continuing Education Program in End-of-Life Care has been as exciting and challenging as the first three if not more. The year has been busy and this report reflects some of the most interesting highlights and innovations of a grueling schedule of educational activities. More details, as in previous years, follow in the table of activities. We have been delighted with the creation of EFPPEC � a much needed initiative to teach all medical school students end-of-life care � and look forward to supporting and helping with these efforts in whatever way is needed. We have also been very excited and consider ourselves very fortunate to have had the opportunity to collaborate with Dr W. Seidelman from Associated Medical Services. The creation of Fellowships in End-of-Life Care is an innovation that will surely improve the quality of care provided to dying patients. We have also been thrilled with the successes in the past year and promise of future success that have arisen from our collaboration with Drs. Alexandra Easson and Lorne Rotstein. We are looking forward to further expansion of our involvement with the Department of Surgery which will serve as a model for other centres to follow. As in past years, the success of the Anderson Program is directly related to the outstanding people we are privileged to work with. This year we were fortunate to expand our teaching faculty this year with the addition of Rabbi Yossi Sapirman, Ms. Judith Wahl, Mr. Mark Handelman, Mr. Nils Riis. In addition we have to extend profoundly felt thanks to Senator Sharon Carstairs for her continued support, Dr. Alexandra Easson, Dr. Lorne Rotstein. Dr. Mary van Soeren, Dr. Anita Singh, Dr. Russell Goldman, Dr. Jennifer Graham, Rev. Adele Miles, Ms Kerry Knickle and others at the Standardized Patient Program, Ms Lucie Forget and Mr. Mark Vimr from Trillium Gift of Life Network, and module authors Dr. Pauline Abrahams, Dr. Gerri Frager and Dr. Yarrow McConnell. Each has brought a new perspective, a new exciting set of skills to the Program and has helped us achieve our goal of improving the quality of education in end-of-life care in Canada. We continue to be recognized for the excellence, quality, practicality and adaptability. In the next year, we hope to further expand our educational resources through the continued development of the pediatric program, completion of the series of educational videos on advance care planning, videos on medical error disclosure and end of life issues in Surgery, OSCE exam for General Surgery trainees to identify further areas in need of improvement and educational material for people near the end of life. We anticipate another busy year, using new educational techniques with standardized patients and families and video.



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We are looking forward to continuing our prominent involvement with the national and provincial governments as they strive to place improving the care of the dying on their health care reform agendas We have enjoyed the expansion of the Anderson program over the last year and are extremely pleased to report on such a very successful fourth year. We eagerly anticipate the next challenges as we continue our efforts to improve the quality of end-of life care across the country. JULY 2004



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Appendices: CAPCE Report Module Authors Executive and Advisory Boards Chart of 2003-2004 Activities



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Comprehensive Advanced Palliative Care Education Program (CAPCE)Comprehensive Advanced Palliative Care Education Program (CAPCE)Comprehensive Advanced Palliative Care Education Program (CAPCE)Comprehensive Advanced Palliative Care Education Program (CAPCE)

Comprehensive Advanced Palliative Care Education Report, page 1/4 Southwestern Ontario Pain and Symptom Management Program June 2004 CAPCE is sponsored by the MOHLTC through the Palliative Care Initiatives of Ontario. CAPCE was developed with input from major stakeholders across the Southwest region including Administrators, Directors of Care, senior management, physicians, nurses, palliative care experts, case managers, pastoral care workers, representing various health care sectors (Palliative Care Stakeholders Planning Day, November 27, 2002). The curriculum is based on palliative care principles and norms as outlined by the Canadian Hospice Palliative Care Association1 and incorporates content and educational techniques adapted from the Ian Anderson Continuing Education Program in End-of-Life Care.2 The program utilizes local professionals with expertise in Hospice Palliative Care (Resource Professionals, Secondary, or Tertiary Consultants/Pain and Symptom Management Educators) to facilitate the CAPCE curriculum and mentor participants. CAPCE is a 90 hour program completed over six months. It was designed to consist of five-day long sessions, representing a total of 30 classroom hours, and 60 hours of homework/practical assignments (approximately 10 hours per month). Two of the sessions are held regionally with all learners (held in London) and three are held in local areas, as facilitated by the local Palliative Pain and Symptom Management Consultants/Educators. Curriculum content includes an introduction to collaboration in palliative care, pain management, symptom management, psychological symptom management, culture, communication, end-of-life decision making, conflict resolution, and last hours. Sessions include pre-read material, active participation through small group discussion and activities (e.g., case studies, role play), and on-the-job homework assignments that are an application of new knowledge. Case studies were specifically developed to be locally relevant and nurse-centered. In the CAPCE program, each learner receives mentorship support throughout the program from their local Palliative Pain and Symptom Management Consultant/Educator. The mentors meet individually with learners in their workplace to facilitate on-the-job transfer of knowledge and skills to clinical practice at the bedside and to assist the organization to meet their goals for delivering Hospice Palliative Care. Furthermore, to facilitate the transfer of knowledge to the workplace the CAPCE program has emphasized the need for organizational commitment to the learner and the involvement of senior management in workplace meetings with program mentors, project development, and the evaluation process.

1 Canadian Hospice Palliative Care Association (March 2002). �A Model to Guide Hospice Palliative Care�. Accessed at: www.chpca.net. 2 Ian Anderson Continuing Education Program in End-of-Life Care. A joint program of Continuing Education and the Joint Centre for Bioethics, University of Toronto, and the Temmy Latner Centre for Palliative Care, Mount Sinai Hospital, Toronto. See: www.cme.utoronto.ca/endoflife.



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Comprehensive Advanced Palliative Care Education Report, page 2/4 Southwestern Ontario Pain and Symptom Management Program June 2004 An important component of the program is the on-line activities designed to increase learners comfort and competence with e-mail and the internet. In an age of increasing technology, the internet is viewed as an essential tool for the palliative care resource person to access best practice information and to network with other experts. A program website was established (www.palliativecareswo.ca) to facilitate communication with and amongst the learners, to provide learners with additional learning resources, and for the completion of evaluation measures and learner reflections. The webmaster served as a coach to teach learners how to use the internet and how to problem-solve any difficulties encountered. Following participation in CAPCE it is expected that learners will serve as Palliative Care Resource Professionals in their organizations, practicing as competent palliative care clinicians and supporting the development of palliative care skills among their peers and colleagues. CAPCE 2003CAPCE 2003CAPCE 2003CAPCE 2003----2004 LEARNERS2004 LEARNERS2004 LEARNERS2004 LEARNERS In addition to the 116 learners registered in CAPCE, there were eight individuals who audited the program and one physician participant. The majority of CAPCE learners were Registered Nurses and work in geriatrics (See Table 1). More than half worked in long-term care settings, with smaller proportions of learners working in acute care and within the community. There was great variability in the amount of time that learners spent providing palliative care (range from 5% to 100% of their time), on average learners spent about 53% of their work time providing palliative care. There was also great variability in the amount of end-of-life/palliative care experience learners had, ranging from less than one year to 35 years, though on average they had 13 years of palliative care experience. The majority of CAPCE learners (63%) had previously participated in palliative care related continuing education initiatives (in-services, education and refresher days, and college courses, other than the Level I Palliative Care Course or the Mentorship Program in Long -Term Care). Learners also participated in various palliative care related conferences (e.g., OPCA, RNAO), initiatives led by local pain and symptom management consultants and other education initiatives such as PIECES, oncology care, children�s grief workshop, wound care, depression in the elderly, and therapeutic touch. PROGRAM EVALUATIONPROGRAM EVALUATIONPROGRAM EVALUATIONPROGRAM EVALUATION An independent evaluation researcher has been retained to conduct an evaluation of the CAPCE 2003-2004 program. The main objective of the initial evaluation was to provide feedback on learners� reactions to the content and format of CAPCE, including the learning strategies used, their reflections on their learning, and their suggestions for program improvement. A longer term evaluation will be conducted in the fall of 2004.



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Comprehensive Advanced Palliative Care Education Report, page 3/4 Southwestern Ontario Pain and Symptom Management Program June 2004 The 2003 � 2004 CAPCE learning initiative was well-received and positively evaluated by learners. Learners reported increased palliative care knowledge and skills and increased confidence with their clinical practice. Their comfort level and use of email and the internet for clinical information increased significantly during the course of the program. Learners provided evidence of their ability to act as Palliative Care Resource Professionals within their workplace � they were able to share new information and skills with peers, to develop palliative care resources for their workplace, and were able to transfer knowledge to their practice, with positive impacts on patient/resident care. Registration is currently being completed for the 2004-2005 CAPCE program. Information gathered from the evaluation of the 2003-2004 has been used to modify the program to better meet the needs of learners and to optimize the likelihood that they will use learned information to improve palliative care in their work settings. CAPCE Program DevelopersCAPCE Program DevelopersCAPCE Program DevelopersCAPCE Program Developers Regional Pain and Symptom Management ConsultantsRegional Pain and Symptom Management ConsultantsRegional Pain and Symptom Management ConsultantsRegional Pain and Symptom Management Consultants

Debbie Burke, Chatham/Kent County Ann Brignell, Sarnia/Lambton County Carole Gill, Windsor and Essex County Nancy Keat, London and Middlesex County Marie Palmer, Grey and Bruce County Ida Tigchelaar, Oxford and Elgin County Judy White, Huron and Perth County

SSSSupportupportupportupport Pat Shanahan, Ministry of Health and Long-Term Care, London, Ontario Julie Girard, Ministry of Health and Long-Term Care, London, Ontario Janice Cosgrove, Complex Care Program, St. Joseph�s Health Care - Parkwood Hospital, London Diane Harris, Learning and Performance Consultant, Tillsonburg, Ontario Loretta M. Hillier, Evaluation Consultant, London, Ontario Denise Eppel, Cabhru Solutions Southwest Region Palliative Education Co-Facilitators Ian Anderson Continuing Education/University of Toronto



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Comprehensive Advanced Palliative Care Education Report, page 4/4 Southwestern Ontario Pain and Symptom Management Program June 2004 ____________________________________________________________________________ Table 1: Description of the CAPCE Table 1: Description of the CAPCE Table 1: Description of the CAPCE Table 1: Description of the CAPCE participants participants participants participants

Number (%) DisciplineDisciplineDisciplineDiscipline (N = 116): Registered Nurse Registered Practical Nurse

94(81.0%) 22 (19.0%)

Workplace settingWorkplace settingWorkplace settingWorkplace setting (N = 115): Teaching hospital Non-teaching hospital Chronic/long-term care/nursing home Community Hospice and/or palliative care program Other settings

5(4.3%) 17 (14.7%) 61 (53.0%) 23 (20.0%) 5 (4.3%) 4 (3.5%)

Practice areaPractice areaPractice areaPractice area (N = 115): Geriatrics Complex continuing care Oncology Primary Care Community nursing Hospice/palliative care Multiple areas

65 (56.5%) 6 (5.2%) 9 (7.8%) 7 (6.1%) 7 (6.0%) 7(6.0%) 14 (12.2%)

Years of palliative care/endYears of palliative care/endYears of palliative care/endYears of palliative care/end----ofofofof----life experiencelife experiencelife experiencelife experience (N = 114) Mean (SD) Range

13.13 years (7.7yrs) 0 � 35 years

Percentage of current work time providing Percentage of current work time providing Percentage of current work time providing Percentage of current work time providing palliative care/endpalliative care/endpalliative care/endpalliative care/end----ofofofof----life care life care life care life care (N = 114) 50% or less of time 51%or more of time

Mean (SD) Range

62 (54.4%) 52 (45.6%) 53.4% (27.6%) 5 -100%



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MODULE AUTHORS Collaboration Laura Hawryluck, MSc, MD, FRCPC (co-author) Physician Leader, Ian Anderson Program, University of Toronto Assistant Professor, Critical Care Medicine, University Health Network David Ryan, PhD, C Psych (co-author) Director of Education, Regional Geriatric Program of Toronto Assistant Professor, Faculty of Medicine, University of Toronto Communications with Patients and Families Laura Hawryluck, MSc, MD, FRCPC Physician Leader, Ian Anderson Program, University of Toronto Assistant Professor, Critical Care Medicine, University Health Network Conflict Resolution Kerry Bowman, MSW, PHD University of Toronto Joint Centre for Bioethics Clinical Bioethicist, Mount Sinai Hospital Assistant Professor, Family and Community Medicine, University of Toronto Culture Kerry Bowman, MSW, PHD Decision-Making in Pediatric Palliative Care Gerri Frager, MD, FRCPC (co-author) Medical Director, Pediatric Palliative Care Service IWK Health Centre, Halifax, Nova Scotia Yarrow McConnell (co-author) Class of 2005, Faculty of Medicine Dalhousie University, Halifax, Nova Scotia End-of-Life Decision-Making Laura Hawryluck, MSc, MD, FRCPC End-of-Life Decision-Making Appendix II � The Law in Ontario Judith Wahl, Advocacy Centre for the Elderly Grief and Bereavement Larry Librach, MD, CCFP, FPFC (co-author) W. Gifford-Jones Professor in Pain Control and Palliative Care, University of Toronto Director, Temmy Latner Centre for Palliative Care, Mount Sinai Hospital



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Pauline Abrahams, BSc,MBChB, CCFP (co-author) Staff Physician, Temmy Latner Centre for Palliative Care Psychosocial Spiritual Program Lecturer, Dept. of Family & Community Medicine, University of Toronto Indigenous Perspectives on Death and Dying Dianne M. Longboat Traditional Teacher and Healer Mohawk Nation The Last Hours Larry Librach, MD, CCFP, FPFC Pain Management Larry Librach, MD, CCFP, FPFC Palliative Care � Standards and Models Russell Goldman, MD, CCFP Assistant Director, The Temmy Latner Centre for Palliative Care, Mount Sinai Hospital, Toronto Psychological Symptoms Larry Librach, MD, CCFP, FPFC Symptom Management Laura Hawryluck, MSc, MD, FRCPC



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IIAANN AANNDDEERRSSOONN PPRROOGGRRAAMM BBOOAARRDD MMEEMMBBEERRSS EXECUTIVE BOARD # Chair: Laura Hawryluck, MSc, MD, FRCPC Physician Leader, Ian Anderson Program, University of Toronto Assistant Professor, Critical Care Medicine, University Health Network # Kerry Bowman, MSW, PHD University of Toronto Joint Centre for Bioethics Clinical Bioethicist, Mount Sinai Hospital Assistant Professor, Family and Community Medicine, University of Toronto # Dave Davis, MD, FCFP

Associate Dean, Continuing Education, Faculty of Medicine, University of Toronto Professor, Health Administration and Family and Community Medicine, University of Toronto # Larry Librach, MD, CCFP, FCFP

W. Gifford-Jones Professor in Pain Control and Palliative Care, University of Toronto Director, Temmy Latner Centre for Palliative Care, Mount Sinai Hospital # Peter A. Singer, MD, MPH, FRCPC Sun Life Chair and Director, University of Toronto Joint Centre for Bioethics ADVISORY BOARD # Chair: Laura Hawryluck, MSc, MD, FRCPC Physician Leader, Ian Anderson Program, University of Toronto Assistant Professor, Critical Care Medicine, University Health Network With representatives from: # The College of Family Physicians of Canada # The Royal College of Physicians & Surgeons of Canada # The Canadian Hospice Palliative Care Association # The Canadian Society of Palliative Care Physicians # The Canadian Medical Association # La Fédération des médecins omnipraticiens du Québec # Health Care Strategies and Policy Directorate, Health Canada

IAN ANDERSON PROGRAM ACTIVITIES 2003-2004

DATE/ LOCATION

EVENT AUDIENCE TITLE SPEAKER(S) EST. ATT.

LOCAL EVENTS May 12 Toronto

Case Presentation: St. Michael's Hospital

End-of-Life Quality Improvement Committee

Case Presentation: Ethics and Law of EOL issues

Laura Hawryluck 12

June 18 Toronto

Toronto East General Family Practice Education Meeting

Family Practice Residents Workshop: Practical Issues of End-of-Life Decision-Making

Laura Hawryluck, Scott Berry

12

October 15 Toronto

Palliative Care Grand Rounds Scarborough CCAC

Multidisciplinary Presentation: Conversations at EOL: decision-making and futility

Laura Hawryluck 99

November 5 Toronto

Toronto Western Hospital Medical Grand Rounds

Multidisciplinary Presentation: Why can't we agree? Laura Hawryluck Linda Wright Wilfred Demajo Mark Handelman

50

November 14-15 Toronto

The Science & Art of Pain and Symptom Management Conference

Multidisciplinary health care providers in palliative care

Debate: For research purposes, palliative care patients should be treated as a �vulnerable population�

Laura Hawryluck Scott Berry

100

Display booth Nancy Bush 260 November 28 Toronto

St. Michael's Hospital Grand Rounds

Multidisciplinary Presentation: Who's got the power? Dealing with demands for treatment

Laura Hawryluck 60

Various Dates Toronto

CRISP sessions for GIM - City Wide

R1-2 GIM residents Various Laura Hawryluck Coordinator, Variety of Speakers

50

January 9 Toronto

University Health Network Psychiatry Grand Rounds

Multidisciplinary Ethics and Law of Consent and Capacity

Laura Hawryluck 30

January 29 Toronto

Toronto General Hospital Medical Grand Rounds

Multidisciplinary Why can't we agree? Ethics and Law of Demands for Treatment

Laura Hawryluck 35

February 19 Toronto

Masters in Health Science Program

Multidisciplinary registrants in MHSc program at U of T

End-of-Life Care in Canada and the Ian Anderson Program

Laura Hawryluck 20

February 26 Toronto

MSc in Bioethics Program (PHIL2145)

MSc Students Substitute Decision-Making and Capacity

Laura Hawryluck Bill Harvey

8


April 6 Toronto

Spring Residency Program University of Toronto Faculty of Nursing; Two-day program on medical ethics

Nurse Practitioner Program Registrants (experienced nurses enrolled in NP Program)

Workshops on: Pain and Symptom Management, Ethics and Law, Approaching End-of-Life Discussions

Laura Hawryluck 20-35

April 7 Hamilton

McMaster University Medicine Academic Day

Hospital physicians including residents

Lectures on Ethics of SARS and Assisted Death/Double Effect

Laura Hawryluck 100

April 20 Toronto

Toronto ICU Fellowship Program ICU Fellows Workshop on 'Legal and Ethical Aspects of Decision-Making: What's new?'

Laura Hawryluck Mark Handelman

12

SUBTOTAL 848 PROVINCIAL EVENTS February 16 Toronto

Trillium Gift of Life Network Workshop

Organ donor coordinators across the Province

Two- day workshop teaching communication skills, ethics and law of brain death and organ donation

Laura Hawryluck Kerry Knickle

26

March 6 Toronto

Trillium Gift of Life Network Workshop

Organ donor coordinators across the Province

One-day day workshop teaching communication skills, ethics and law of brain death and organ donation

Laura Hawryluck Kerry Knickle Lucie Forget

22

May 30-31 London

Anderson Program Conference Palliative care physicians and nurses

Two-day core content and opinion leader program training for use in palliative care education program to be used in seven pain and symptom management regions

Jennifer Graham Adele Miles Mary Van Soeren

34

September 6 London

Anderson Program Conference Palliative care physicians and nurses

One-day facilitator training program Training for use in palliative care education program to be used in seven pain and symptom management regions

Larry Librach 30

September 10 Belleville

Bioethics Committee of Quinte Healthcare Corporation DNR Conference

Multidisciplinary Workshops (two): CPR: The past, the present and the controversies Demands for Treatment

Laura Hawryluck 100

September 19 Thunder Bay Northern Educational Centre for

Aging and Health, Lakehead University and Thunder Bay Medical Society Lakehead Summer School

Multidisciplinary Workshop: The Quest for One Ring: Patient demands and rights to treatment

Laura Hawryluck 15



5th Annual AMS-COFM Conference: Bringing back the humanity; teaching how to care

Provincial Schools of Medicine faculty and staff

Two-day conference development for Ontario medical schools funded by Associated Medical Services

Laura Hawryluck Larry Librach Dave Davis

50

November 13 London Ontario College of Family

Physicians

Members of the OCFP One-day workshop: Advance Care Planning Physician Training Initiative

Laura Hawryluck Judith Wahl

8


Annual Nurse Practitioner Conference: Celebrating 30 Years of Practice

Nurse practitioners Workshop (presented twice): End-of-Life Care

Laura Hawryluck 90

November 19 Toronto Ontario College of Family

Physicians

Members of the OCFP One-day workshop: Advance Care Planning Physician Training Initiative

Larry Librach Judith Wahl

12


Paediatric Oncology Group of Ontario Conference

Multidisciplinary healthcare providers

Display booth Nancy Bush 300

March 26 Cobourg,

Ian Anderson Program Core Content Training Workshop


One-day workshop with core content training in four program modules

Russell Goldman Mary van Soeren

50

April 26 Toronto

14th Annual Provincial Conference on Palliative and End-of-Life Care, April 25-27


Workshop (presented twice): Communication in the Doctor-Patient Relationship: "Pathological Denial"

Laura Hawryluck 40

April 25-27 Toronto

14th Annual Provincial Conference on Palliative and End-of-Life Care


Display booth Nancy Bush 500

SUBTOTAL 1277 NATIONAL EVENTS June 4-6 Winnipeg

University of Manitoba Critical Care Program

Critical care residents and nurses

Medical Grand Rounds Resident teaching using standardized patient workshops

Laura Hawryluck Diane Longboat Mary van Soeren

120

June 15-18 Quebec City

Canadian Hospice Palliative Care Association Conference

Multidisciplinary Exhibit table Nancy Bush 800

September 13 Halifax

Annual Conference of the Royal College of Physicians and Surgeons of Canada

Royal College Members Workshop: Bringing back humanism to enhance professionalism in residency education

Alexandrea Easson Laura Hawryluck Lorne Rotstein

8


October 31 Toronto

Toronto Critical Care Medicine Conference

Intensivists/ ICU healthcare providers

Workshop: End of Life Ethics in the ICU

Laura Hawryluck Mary van Soeren Jean Louis Vincent Graeme Rocker

30

October 31 Toronto

Toronto Critical Care Medicine Conference

Intensivists/ ICU healthcare providers

Communicating about brain death and organ donation: the state of the art. Workshop in collaboration with Trillium Gift of Life Network

Kerry Knickle Laura Hawryluck Lucie Forget

15

SUBTOTAL 973

INTERNATIONAL February 11 Internet Webcast

Pall Medical Webcast Multidisciplinary SARS: Infection Control Challenges in the ICU

Laura Hawryluck 100

March 9 Havana, Cuba

International Symposium on Coma and Death; March 9-12; Havana, Cuba

Multidisciplinary Workshop: Brain death and organ donation: teaching communication skills

Laura Hawryluck Kerry Knickle Laura Jane Nelles

30

SUBTOTAL 130

TOTAL ESTIMATED ATTENDANCE

3,228

PROGRAM DEVELOPMENT &

RESEARCH

2002-2003 Royal College General Surgery Exams

Ethics and EOL Care subjects Question design Laura Hawryluck Alexandra Easson

2003 Improving EOL care on General Internal Medicine Wards

AMS Wilson UHN Awards Laura Hawryluck

2002-2003 Incorporating EOL Care Into General Surgery program

General Surgery Residents Alexandra Easson Lorne Rotsein Laura Hawryluck

2002-2003 Trillium Gift of Life Network Organ donor coordinators Workshop (standardized family scenarios, core content program development) educational videos



2003-2004 Trillium Gift of Life Network 5 videos ( 4 in English, one in French) Teaching tool for Organ Donor Coordinators, staff, residents and fellows

Laura hawryluck, Kerry Knickle

2002-2004 Anderson Pediatric End-of-Life Care Educational Program

Pediatric palliative care specialists

Module and workshop development Gerri Frager Yarrow McConnell Laura Hawryluck

Spring 2003 ICU Fellowship Exam ICU Fellows ICU Fellowship exam using standardized patients

Laura Hawryluck

Website for HCP/families--- Oncology PMH

Jennifer Jones et al, Laura Hawryluck

GRANTS

2003 Improving EOL care on General Internal Medicine Wards

AMS UHN wards Research project/ faculty development Laura Hawryluck $5,000.00

2002-2003 Trillium Gift of Life Network Organ donor coordinators Workshop (standardized family scenarios, core content program development) educational videos


$84,000.00

New Emerging Teams/ CIHR grant application

Improving Quality End of Life Care in Oncology

Gary Rodin, Laura Hawryluck, Alex Haddad, Larry Librach, Kerry Bowman et al

Dean's Fund Teaching Surgeons communication skills at EOL

Alexandra Easson, Laura Hawryluck

$20,000.00

American College of Surgery, Department of Surgery U of T

Teaching Surgeons communication skills at EOL

Alexandra Easson, Laura Hawryluck

$22,000.00

TOTAL GRANT FUNDING RECEIVED

$131,000.00

Documents

IAN ANDERSON CONTINUING EDUCATION PROGRAM IN END-OF … · 2017-03-20 · Ian Anderson Continuing Education Program in End-of-Life Care University of Toronto Annual Report 2003-2004