Foundation focuses on pass-along knowledge

AMA program spreads the word

Years ago, a shampoo commercial invited consumers to tell two friends about the shampoo, who would in turn tell two friends, and so on, and so on. That has been the premise behind the Robert Wood Johnson Foundation-supported Education for Physicians on End of Life Care (EPEC) and one of the best hopes for increased awareness in palliative care.

For more than three years, the American Medical Association-developed program has been training physicians in end-of-life care with the expectation that those same physicians would go back to their facilities and educate their colleagues and community about end-of-life care. By the accounts of those providing the training, the program has been a success. But there is still a long way to go.

"We’ve gone well beyond our own expectations, but that is tempered by the reality of what we faced," says Jennifer Fowler, MPA, project coordinator for Journey’s End, a foundation-funded end-of-life state initiative in Louisville, KY, that has been training physicians, nurses, social workers and chaplains using the EPEC curriculum.

The reality she speaks of is the same reality that hospices face every day — the lack of palliative care knowledge among physicians that translates into inappropriate care decisions at the end of a patient’s life. The success of EPEC bodes well for hospices that depend largely on physician referrals

Dissemination of the EPEC Curriculum began with two national conferences held in the spring of 1998 to introduce an abbreviated version of the curriculum to national leaders in medicine. In the first half of 1999, six regional conferences presented EPEC to a select group of 500 physician-educators for implementation in their own institutions or communities.

To date, more than 1,000 physicians have been trained to teach their colleagues about end-of-life care through EPEC, says Jeanne Martinez, RN, MPH, CHPN, associate director for outreach and technical assistance with EPEC in Chicago.

The EPEC initiative has taught physicians about communication, decision making, medical ethics, legal issues surrounding palliative care, palliative medicine and hospice care, psychosocial management, and pain and symptom management, which applies to both terminal and non-terminal conditions.

Upon completion of the program, participants are able to:

• define advance care planning and explain its importance;

• counsel patients on use of advance directives;

• identify the six-step protocol for delivering "bad" news;

• describe and assess the elements of suffering and the role of the interdisciplinary model;

• compare and contrast nociceptive and neuropathic pain symptoms, physiology, and treatment;

• define physician-assisted suicide and describe its current legal status;

• distinguish terminal sedation from assisted suicide;

• recognize terminal illness;

• enhance effective teaching skills.

More importantly, physicians are in a position to preach the gospel of end-of-life care to physicians in their own community. Both Martinez and Fowler say that EPEC-trained physicians are in demand and that these new disciples of palliative care are having a hard time keeping up with the demand for information.

The hospice role, says Martinez, is to aid EPEC physicians in reaching out to the rest of the physician community and health care facilities. Hospice medical directors, while already schooled in end-of-life care, could benefit from EPEC’s teaching seminars to improve their skills in communicating their expertise to others.

"There is such a demand for trainers," says Martinez.

The EPEC Curriculum consists of four 30-minute plenary modules and a dozen 45-minute workshop modules. Developers of the curriculum say its value lies, in part, in its practicality and portability. (For details of the workshop modules, see listing on p. 114.)

While the AMA developed the training program for physicians, Journey’s End has included nurses, and has encouraged physicians who take the course to recruit nurses and social workers to take it as well, to promote an interdisciplinary approach to improving end-of-life care.

Journey’s End began training physicians and nurses using EPEC last fall. So far, little more than a handful of physicians and nurses have gone through the program. Project officials hope to have as many as 70 EPEC-trained physicians and nurses by year’s end and 140 by the time the grant expires.

[Editor’s note: For more information about EPEC, write to The EPEC Project, Institute for Ethics, American Medical Association, 515 N. State St., Chicago, IL 60610. Telephone: (312) 464-4979. E-mail:]