1. To show students that the therapeutic process involves more than diagnosing and attempting to revert an altered pathophysiologic process and that illness is a complex state with physical, emotional, psychosocial, and spiritual elements.
2. To demonstrate the interdisciplinary approach of Palliative Care.
3. To demonstrate preventive steps to avoid physical, psychosocial, and emotional problems.
4. To emphasize that all interventions should be centered on the patient's needs, desires, and beliefs, thus ensuring patient control, whenever possible, of decisions which affect them.
5. To have students identify their own attitudes toward death and to identify and respect family attitudes toward death.
6. To enable students to understand the unit of care, the family,

7. *	Copyright 1991 by Dr. Neil MacDonald for The Canadian Committee on Palliative Care Education, used with permission.

7. through consideration of the family background and the impact of illness upon the family group.
8. To demonstrate how the impact and interpretation of illness depends on personal attitudes by providing examples of harmonizing the Canadian medical model of care with the cultural and spiritual backgrounds of patients and families.
9. To involve students in discussions on ethical aspects of caregiving including euthanasia, resuscitation, truth telling, paternalism, aggressive versus palliative interventional therapy, incompetent patients, fairness in the health care system, and strategies for resolving ethical issues.

9. To enable students to integrate knowledge from across disciplines and to critically appraise clinical data, diagnostic tests, and the literature in order to assist with decisions to initiate or stop various investigations and therapy.
10. To demonstrate various techniques for communication with patients and families as well as how and why these techniques would be modified based on the personal, educational, and cultural background of the patient and family.

11. To describe the pathophysiology of common distressing symptoms in patients with advanced chronic disease and to suggest appropriate pharmacologic and non-pharmacologic techniques to combat these symptoms.
12. To have students identify various organizational arrangements for delivery of Palliative Care and the relationship of these organizational structures to the existing health care system including the community resources available to patients with advanced illness and their families.
13. To describe the elements of grief reactions and some techniques to prevent the development of pathologic reactions through caring for the patient and bereaved family.

J. Andrew Billings, M.D., and Susan Block, M.D.

Caring for patients at the end of life is a basic task of doctoring and one for which students receive relatively little preparation and instruction. This

course will combine clinical experiences and readings to provide students with the fundamental knowledge, attitudes, and skills necessary in caring for patients near the end of life. The focal learning experience in the course will be the student's relationship with a patient with a life-threatening illness. Opportunities will be offered in small groups for reflection on personal reactions to the patient, the patient's illness, and the dying process and for receiving supervision about working with the patients from a clinician experienced in caring for dying patients. Six or seven structured learning experiences (panel discussions, large group case discussions, seminars, and lectures) addressing topics such as responses to suffering, symptom control, grief and loss, spiritual issues, and ethical dilemmas will also be offered.

• Students will learn the basic elements of the hospice philosophy of care.
• Students will understand the impact of inadequately controlled physical and psychological symptoms on quality of life in patients with life-threatening illness.
• Students will learn the most common physical and psychological symptoms that accompany terminal illness.
• Students will explore the roles of ethical principles (e.g. autonomy, beneficence, non-malfeasance) in making decisionmaking near the end of life.
• Students will learn the phenomenology and course of the grieving process and its impact on physical and psychological health.
• Students will learn about different cultural, religious, and spiritual constructs of the meaning of death and the impact on the experience of life-threatening illness.
• Students will gain an understanding of the experience, for patients and families, of a life-threatening illness.

• Students will enhance skills in creating a relationship which fosters the disclosure of intimate and sensitive material about responses to illness.
• Students will acquire skills in communicating with patients and their families about desires for care at the end of life.

• Students will enhance their appreciation of how their own feelings about death affect their interactions with patients.
• Students will enhance their understanding of the meanings of death to physicians within the culture of medicine.
• Students will gain understanding of physicians' adaptive and maladaptive responses to dying patients.
• Students will gain enhanced appreciation of patients as teachers about the process of illness and the experience of receiving medical care.

Billings J.A. The Doctor and the Dying Patient, in Billings, JA, Stoeckle J. The Clinical Encounter. Chicago, Year Book Medical Publisher, 1989, pp. 193–199.

Cassem N.H. The Person Confronting Death, in Nicholi AM. The New Harvard Guide to Modern Psychiatry. Cambridge, Harvard University Press, 1988, pp. 728–758.

Quill T.E. Bad News: Delivery, Dialogue, and Dilemmas. Archives of Internal Medicine, 151:463–468, 1991.

Weisman A.D. The Coping Process/Coping and Denial (Chapters 3 and 4), in Coping with Cancer. New York, McGraw-Hill, 1979, pp. 27–55.

Nuland S. Hope and the Cancer Patient/The Lessons Learned (Chapters 11 and 12), in Nuland S. How We Die. New York, Knopf Publishing, 1994, pp. 222–262.

Callahan, D. Nature, Death, and Meaning: Shaping Our End, in The Troubled Dream of Life. pp. 157–186.^*

Cassel E.J. The Nature of Suffering and the Goals of Medicine. New England Journal of Medicine, 306:639–645, 1989.^*

Bulkin W, Lukashok H. Rx for Dying: The Case for Hospice. New England Journal of Medicine, 318(6):376–378, 1988.

Billings JA. Specialized Care of the Terminally Ill Patient, in Care: Principles and Practice of Oncology, vol. 2. Philadelphia, Lippincott, 1989, pp. 2237–2244.

Management of Cancer Pain. Clinical Practice Guideline: U.S. Department of Health and Human Services, Agency for Health Care Policy & Research. Publication no. 94-0592, March 1994.^*

Baer K. Guide to Hospice Care. Harvard Health Letter Special Supplement. April 1993.^*

Broyard A. Intoxicated by My Illness and Other Writings on Life and Death. New York, C. Potter, 1992, pp. 33–58.

Trillin A.S. Of Dragons and Garden Peas: A Cancer Patient Talks to Doctors. N Engl J Med. 304(12):699–701, 1981.

Frank A. Seeing Through Pain, in At the Will of the Body. Boston, Houghton-Mifflin, 1981, pp. 29–35.

Caralis P.V. et al. The Influence of Ethnicity and Race toward Advance Directives, Life-Prolonging Treatments, and Euthanasia. Journal of Clinical Ethics, 4(2)155–165, 1993.

Blackhall L.J. et al. Ethnicity and Attitudes Toward Patient Autonomy. Journal of the American Medical Association, 274:820–825, 1995.

Carresse J.A., Rodes, L.A. Western Bioethics on the Navajo Reservation. Journal of the American Medical Association, 274:826–829, 1995.

Miles SH, August A. Courts, Gender and "the Right to Die". Law, Medicine and Health Care, 18(1—2):85—9).1990^*

Zinsser H. As I Remember Him: The Biography of R.S. Boston: Little, Brown, 1939, pp. 437–443.^*

Lichstein P.R. Terminating the Doctor/Patient Relationship, in Lipkin M, et al. The Medical Interview: Clinical Care, Education and Research . New York, Springer-Verlag, 1994, pp.196–206.

White L.P. The Self-Image of the Physician and the Care of Dying Patients. Annals of the New York Academy of Sciences, 164(3):822–831, 1964.

Morrison R.S. et al. Physician Reluctance to Discuss Advance Directives: An Empiric Investigation of Potential Barriers. Archives of Internal Medicine, 154:2311–2318, 1994.

Pfeifer M.P. et al. The Discussion of End-of-Life Medical Care by Primary Care Patients and Physicians: A Multicenter Study Using Structured Qualitative Interviews. Journal of General Internal Medicine, 9(Feb):82–88, 1994.

Markson LJ et al. Implementing Advance Directives in the Primary Care Setting. Archives of Internal Medicine, 154:2321–2327, 1994.^*

Weeks WB et al. Advance Directives and the Cost of Terminal Hospitalization. Archives of Internal Medicine, 154:2077–2083, 1994.^*

Brock, Death and Dying, in Life-and-Death Decisions in the Clinic. pp. 144–183.

Quill T. Death and Dignity: A Case for Individualized DecisionMaking. New England Journal of Medicine, 324(10):691–694, 1991.

SUPPORT Principal Investigators. A Controlled Trial to Improve Care for Seriously Ill Hospitalized Patients. Journal of the American Medical Association, 274:1591–1598, 1995.

Solomon A. A Death of One's Own. The New Yorker. May 22, 1995:54–69.

Evans RW, Orians C.E., Ascher N.L., The Potential Supply of Organ Donors: An Assessment of the Efficiency of Organ Procurement Efforts in the United States. Journal of the American Medical Association, 267(2)239–245, 1992.^*

Veatch RM. The Shortage of Organs for Transplantation: Where Do We Go From Here? New England Journal of Medicine, 325(17):1243–1249, 1991.^*

Cain JM, Hammes BJ. Ethics and Pain Management: Respecting Patient Wishes. Journal of Pain and Symptom Management, 9(3):160–164, 1994. ^*

Neuberger J. Cultural Issues in Palliative Care. pp. 507–513.

Chekhov, A. Grief.

Beattie A. In the White Night. The New Yorker. June 4, 1984: 42–43.

Lindemann E. Symptomatology and Management of Acute Grief. American Journal of Psychiatry, 101:141–148, 1944.

Osterweis M., et al. Epidemiologic Perspectives on the Health Consequences of Bereavement, in Bereavement: Reactions, Consequences and Care. Washington, D.C., National Academy Press, 1984: pp. 15–44.

Ross E.K. Adults' Reactions to Bereavement, in Bereavement: Reactions, Consequences and Care. Washington, D.C., National Academy Press, 1984:47–68.

Irvine P. The Attending at the Funeral. New England Journal of Medicine , 312(26):1704–1705, 1985.

Moss H. Elegy for My Sister. New Selected Poems. New York, Atheneum, 1985.

Billings J.A. On Being a Reluctant Physicians—Strains and Rewards in Caring of Dying at Home, in Outpatient Management of Advanced Cancer, Philadelphia, Lippincott, 1985: pp. 309–318.

• First patient visit: Introduction and discussion of patient's current status, how he or she learned about his or her illness, and his or her feelings about his or her current medical situation.
• Second patient visit with special attention to pain and symptom control issues.
• Third patient visit: Focus on cultural issues and desires for care at the end of life.
• Fourth patient visit: Focus on religious and spiritual issues.
• Complete a personal advance directive.
• Fifth patient visit: Spiritual assessment.
• Sixth patient visit: As a volunteer, helping with some aspect of patient's care, saying goodbye.