Artificial Nutrition and Hydration in Terminally Ill Patients

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Table of Contents

Introduction for the Learner (Resident/Oncology Fellow) . . . . 2

Introduction for Clinical Faculty Evaluator . . . . 2

Part 1: Learning Objectives . . . . 3

Part 2: Teaching Outline . . . . 4

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Introduction for the Clinical Faculty Evaluator How to perform this competency assessment

A Medical Resident or Oncology Fellow has requested that you assess their competency in a selected palliative care domain during the time you are the Clinical Faculty Evaluator/attend-ing physician on this service . To assist you with this evaluation, please do the following .

Preparing for field evaluation of competency

Review this Competency Assessment Tool thoroughly includ-•

ing the Learning Objectives (Part 1), Teaching Outline (Part 2) and Evaluation Checklist (Part 3) prior to pre-discussion counseling with Resident (required) .

Review Unit II, Module 2 (Anorexia and Cachexia) and Unit •

III, Module 2 (Setting Treatment Goals) of the web-based pal-liative care training program . The training program is available on the UMMS Intranet, click on Physicians . The course is list-ed under “Helpful Links .” It is also available via the internet at http://134 .192 .120 .12/canRes/htdocs/login .asp (optional) . Format of competency evaluation

During the clinical rotation

Based on the Teaching Outline and Evaluation Checklist in •

this document and the content in Unit II and Unit III of the palliative care training website, evaluate how the Resident or Fellow understands and discusses this issue with a patient and/ or their healthcare agent or proxy, and documents this discus-sion in the patient record, or in an advance care planning docu-ment such as the state of Maryland “Instructions on Current Life-Sustaining Treatment Options” form .

Suggested behaviors include: •

Reviewing facts of case before discussion with patient/family

-Not delegating task

-Appropriate setting – e .g ., sitting in a quiet, safe area

-Including appropriate individuals in discussion

-First reviewing general goals of care

-Contextualizing feeding issues within goals of care

-Allowing time for patient/family discussion

-Setting up follow-up as appropriate

-Documentation in chart and/or on form

-End-of-rotation feedback

Review strengths and weaknesses of competency evaluation •

with Resident/Fellow

Provide constructive feedback to improve Residents/Fellows’ •

performance and patient outcomes .

Complete Evaluation Checklist (Part 3 of this document) Share with Resident/Fellow; allow Resident/Fellow to make •

his/her own self-assessment of competency performance Clinical Faculty Evaluator/attending and Resident/Fellow must •

sign this Evaluation Checklist (Part 3)

Resident/Fellow is responsible for returning Evaluation •

Checklist to Dr . Wolfsthal (Residents) or Dr . Mannuel (Fel-lows)

Introduction for the Learner (Resident/Fellow) Prior to your evaluation of competency

Complete the web-based palliative care training pro-•

gram “Medical Resident Training in End-of-Life and Pal-liative Care” before you undergo this competency assess-ment . The training program is available on the UMMS Intranet, click on Physicians . The course is listed under “Helpful Links .” It is also available via the internet at http://134 .192 .120 .12/canRes/htdocs/login .asp

Review Part 1 (Learning Objectives), Part 2 (Teaching

-Outline) and Part 3 (Evaluation Checklist) of this document THOROUGHLY so that you are aware of what is required of you .

Review Unit V, Ethical and Legal Issues of the Web-based pal-•

liative care training program .

Ascertain that the attending/faculty member is certified to •

conduct the Palliative Care Competency Evaluation . Field evaluation of competency

During the course of a clinical rotation, it is anticipated that •

you will have opportunities to demonstrate your competency in discussing Withdrawal of Life-Sustaining Medical Treat-ments that are not meeting the treatment goals for a patient with a terminal illness during morning work rounds with your Clinical Faculty Evaluator/attending, and also throughout the day or during times of night call or cross-coverage .

Identify a faculty member to evaluate your competency – •

current service attending recommended, if s/he is certified to conduct evaluation .

ASK FACULTY MEMBER TO REVIEW THIS COMPE-•

TENCY ASSESSMENT TOOL PRIOR TO YOUR PER-FORMING THIS TASK .

Faculty must accompany and observe Resident . •

Faculty completes Evaluation Checklist (Part 3) and shares •

with you .

You will also complete the self-evaluation portion of the •

Evaluation Checklist as a measure of competency in practice based learning .

Evaluation Checklist must be signed by the Clinical Faculty •

Evaluator/attending and you (Resident/Fellow) .

Return Evaluation Checklist to Dr . Susan Wolfsthal, Internal •

Medicine Residency Director or Dr . Heather Mannuel, Medi-cal Oncology Fellowship Director .

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Part 1: Learning Objectives

Note to learner and Clinical Faculty Evaluator: The Learning Objectives are listed in terms of fulfilling the six ACGME core compe-tencies, listed below; these are reflected in Evaluation Checklist in Part 3 of this document .

LEGEND to ACGME core competencies: http://www .acgme .org/Outcome

OBJECTIVES –

A competent Medical Resident or Oncology Fellow will be able to:

ACGME Competencies

PC MK PBL&I IPCS P SBP

Discuss the ethical and legal principles guiding withdrawal of nutrition and hydration in a terminally ill patient.

X

Illustrate situations when it is appropriate to discuss withdrawal or withholding of artificial nutrition or hydration in terminally ill patients.

X X

List, in legal order, who can make decisions for a non-decisional patient. X X

Discuss the benefits and burdens of appetite stimulants in terminally ill patients. X

Recognize cachexia syndromes associated with terminal illnesses. X X X X

Partner effectively and efficiently with allied health professionals when planning a discus-sion of withholding or withdrawing artificial nutrition or hydration.

X X X

Manage conflicts between physician care recommendations for artificial nutrition and hydration and requests for artificial feeding/hydration from the patient/proxy/family.

X X

LEGEND: PC – Patient Care MK – Medical Knowledge

PBL&I – Practice-Based Learning and Improvement IPCS – Interpersonal and Communication Skills P – Professionalism

SBP – Systems-Based Practice

(Adapted from Weissman, DE, Ambuel, B, Hallenbeck, JL . Improving end-of-life care: A resource guide for physician education. 4th ed. Milwaukee: Medical College of Wisconsin, 2007 and Emanuel LL, von Gunten CF, Ferris FD . The Education in Palliative and End-of-life Care [EPEC] Curriculum . Chicago: American Medical Association; 1999) .

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Proxy – a person or persons who speak(s) on behalf of the patient, usually determined by the hierarchy listed in Maryland’s Health Care Decisions act which is as follows, beginning with proxy of highest priority):

Court appointed guardian • Spouse • Adult children • Parents • Adult siblings •

Friends or other relatives •

Data Concerning the Medical Effectiveness of Non-Oral Feed-ing/Hydration in Advanced Dementia3-5

Benefits

Psychological benefits for family members and caregivers include:

Maintaining appearance of life-giving sustenance •

Maintaining hope for future cognitive improvement •

Removal/avoidance of guilt about making a decision to with-•

draw/withhold non-oral feeding and hydration Unproven benefits

There is no medical evidence to confirm that provision of non-oral feeding or hydration in patients with late-stage dementia will meet the following goals, and a growing body of evidence that indicates that provision of such treatments will do the op-posite of:

Reduction in aspiration pneumonia •

Reduction in patient suffering •

Reduction in infections or skin breakdown •

Improved survival duration (in a population of similar pa-•

tients) Burdens

Risk of aspiration pneumonia is the same or greater than with-•

out non-oral feeding

Increased need to use physical restraints •

Wound infections, abdominal pain, and tube-related discom-•

fort (especially naso-gastric tubes) Cost

Indignity •

Possible decreased prognosis in some cancer patients •

Ethical Principles6-9

There is no mandate to provide non-oral feeding/hydration to 1 .

a patient with a terminal illness when the burden/risk of feed-ing is greater than the benefit .

As with any medical procedure, decisions to institute, with-2 .

hold, or withdraw non-oral feeding should involve patient or designated proxy and include full informed consent dis-cussion regarding the benefits/burdens associated with the action .

Part 2: Teaching Outline for Learner and Clinical Faculty

Evaluator

The public is increasingly concerned that death not be artificially prolonged1 . In the absence of an advance directive, the place-ment and long-term maintenance of feeding tubes in patients with late-stage dementia and other terminal illnesses has become a common practice; Despite this, multiple sources of evidence indicate little benefit, but substantial burden, to this practice2-4 . These guidelines provide a framework for decision-making about the use of non-oral feeding and hydration in late-stage dementia and related conditions, taking into account current medical evidence, legal and ethical principles, cultural and reli-gious values .

Definitions

Non-Oral feeding – provision of food by nasogastric [NG] tube, gastrostomy [G] tube, or Gastro-jejunostomy [G-J] tube, or Total Parenteral Nutrition [TPN]

Artificial Hydration – provision of water or electrolyte solu-tions by any non-oral route (intravenous, hypodermoclysis, NG/G/GJ tube)

Advanced Late Stage Dementia (Advanced cognitive loss)

– progressive, terminal illness, caused by one of a number of conditions including Alzheimer’s disease, cerebrovascular dis-ease, congenital or acquired neuro-degenerative diseases, brain tumors, AIDS, Parkinson’s diseases, etc .

Diagnostic features include:

Loss of higher cognitive function including memory and judg-•

ment

Loss of intelligible speech •

Inability to interact meaningfully with family/friends •

Inability to maintain oral nutrition due to loss of swallowing •

reflex

Inability to ambulate •

Increasing need for medical attention due to complications of •

dementia Natural History5

Progressive dementia is a terminal illness. When patients can no longer eat, speak or ambulate, the median survival is approxi-mately 6-12 months, depending on the level of medical interven-tion for intercurrent illnesses (e .g ., urosepsis) .

Cachexia – a syndrome that is characterized by alteration in metabolism with fat and protein wasting, which is a common end-stage phenomenon in many terminal diseases .

Surrogate – a specifically designated person, normally the dura-ble power of attorney for medical affairs, who speaks on behalf of the patient when they are unable to speak for themselves . A person named as surrogate in an advance directive in the state of Mary-land is called the patient’s “healthcare agent .” If the adult patient does not have an advance directive with healthcare agent stated, then a proxy is used to speak on the patient’s behalf – see proxy .

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Many, but not all, religions recognize that death is a normal 2 .

aspect of life and that non-oral feeding/hydration may be discontinued when the burden exceeds the benefit . However, this is not a universally held religious belief; when in doubt, clinicians should consult with the hospital chaplain staff or patient’s spiritual leader .

Physicians themselves have deeply held cultural and reli-3 .

gious values surrounding the issue of feeding . Such personal feelings must be respected, but not allowed to interfere with the presentation of all reasonable facts and recommendations to families or surrogate decision-makers .

Information for Physicians when Counseling Patients, Fami-lies or Surrogate Decision-Makers/Proxies

Alternatives to artificial nutrition (enteral or TPN) and hydra-tion3-5,9

When a decision is being made to either discontinue artificial feeding or not to begin such feeding, ethical and medical alterna-tives often exist:

In the absence of artificial nutrition and hydration, foods and •

fluids can be offered by mouth, as tolerated, prepared in a man-ner that will lessen the aspiration risk (e .g ., thickened liquids) . There are no data indicating that withdrawal/withholding of •

non-oral food from patients with late-stage terminal illnesses or dementia causes suffering when adequate comfort measures are instituted .

Note: The dying patient typically has no or little appe

-tite; moreover, ketosis will blunt the symptom of hunger . Moistening the lips and good mouth care usually alleviates the symptom of a dry mouth . There are good data to support that provision of non-oral hydration, by itself, will not cor-rect the symptom of dry mouth among the terminally ill .9 Aggressive comfort measures will always be provided, e .g ., •

Pain and symptom management

-Moistening agents to lips and mouth

-Frequent change of body position

-Family support

-Provide patient and family education; •

Discuss ineffectiveness and discomfort of forced feeding

-and artificial nutrition/hydration

Suggest replacing caregiver “need to feed” with behaviors

-that alleviate symptoms…

Eliminate dietary restrictions - eat p .r .n . in amount desired

-Reduce portion size, more frequent meals

-Pharmacologic measures – in cases where anorexia prevents •

oral intake, consider a timed trial of appetite stimulants: Dexamethasone 2 to 20 mg po qAM – use only if life expec

-tancy is less than 3 weeks because of Cushingoid and other side effects

Megesterol (Megace), 200 mg po q6-8 hrs, titrated to

-achieve desired effect . Beware of thromboembolic and other side effects

Non-oral feeding/hydration is considered a medical treat-3 .

ment, not “ordinary care .” “Ordinary care” includes provi-sion of oral food and water, bathing, dressing, keeping a patient safe, warm and comfortable .

The decision to withhold or withdraw non-oral feeding/hy-4 .

dration in this setting is not euthanasia (the active administra-tion of a drug/procedure by a physician to induce death) . The decision to withhold or withdraw non-oral feeding/hy-5 .

dration in this setting is not assisted suicide (the provision of a lethal drug/procedure to a patient, with their full knowledge that the drug/procedure can be used by the patient to induce death at the time/place of the patient’s choice) .

Patients who do not have decision-making capacity (non-6 .

decisional) may have non-oral feeding/hydration withdrawn or withheld in the following situations (NOTE: the following represents Maryland law – you should check on applicable laws in your own state):

If the patient has requested withholding/ withdrawing artifi

-cial nutrition and/or hydration on a valid advance directive (Durable Power of Attorney (for health care), a Living Will, or a documented conversation with a physician), and the terms of the request are met .

If the patient’s proxy has requested withdrawal or with

-holding and the patient is certified to be terminally ill, in an end-stage medical condition with complete functional de-pendency, or is in a persistent vegetative state; as determined and documented in accordance with Maryland’s Health Care Decision Act (as amended) .

If two physicians have certified in writing that non-oral

-feeding/hydration is medically ineffective, and have notified the patient or their proxy that this “Life-sustaining medical intervention” is no longer effective and will be withdrawn . This last provision is rarely used in Maryland, and when it is used, it is often reviewed by a Patient Care Advisory Com-mittee (“ethics comCom-mittee”) . In an emergency room only one physician needs to certify medical ineffectiveness and communicate this to the patient/proxy [see further Health Care Decisions Act § 5-611] .

In cases where the decision to withhold or withdraw any po-7 .

tential life-sustaining medical treatment is not clear, anyone directly involved in the patient’s care may request a review by the hospital (or nursing home) Patient Care Advisory Committee (Maryland’s “ethics committees”) . The commit-tee will provide advice on the particular case, which is often useful for clarifying and resolving complex cases, and may give Maryland care-providers certain statutory protections . Religious/Cultural Values Concerning Food/Water

The act of eating and the provision of food to the sick are 1 .

important cultural symbols signifying life and hope . Thus the withdrawal or withholding of food often appears contrary to normal societal values . Families will often mistakenly equate withdrawal or withholding of food with starvation, euthana-sia or murder .

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ings, and hand-feeding is not an option (e .g ., diminished level of arousal), and intravenous hydration is not started, families/surrogates should be advised that death will likely ensue within 14 days and that all comfort measures will be continued .

Document the current decisions on the Instructions for Cur-6 .

rent Life-sustaining Options form for the state of Maryland (included in this document), or the advance care planning note for the VA hospital, and place a note on the medical record . The Maryland form should be completed as per instructions, with initials (not “check-marks”), and placed on the front of the medical record . This form should also ac-company the patient through all transfers .

The note on the medical record should indicate who was 7 .

present to discuss the issues, what issues were discussed, and what the results of the discussion were . The note should be dated, timed, and signed .

References

Approaching death: improving care at the end of life.

1 .

Com-mittee on care at the end of life, Division of Health Care Services, Institute of Medicine, National Academy of Sci-ences, 1997 .

Finucane TE, Christmas C and Travis K . Tube feeding in pa-2 .

tients with advanced dementia . JAMA 1999; 282:1365-1370 . McCann, R . Lack of evidence about tube feedings – food for 3 .

thought . JAMA 1999; 282:1380-1381

Gillick MR . Re-thinking the role of tube feeding in patients 4 .

with advanced dementia . N Engl J Med. 2000; 342:206-209 . Medical Guidelines for Determining Prognosis in Selected 5 .

non-Cancer Diseases., 2nd Edition. National Hospice Orga-nization . 1996

Code of Medical Ethics; Council on Ethical and Judicial Af-6 .

fairs, American Medical Association, 1998-99 .

AMA council of scientific affairs . Good care of the dying 7 .

patient . JAMA 1996; 225:476-478 .

Froedtert Hospital Medical Staff Policy: Withdrawal/with-8 .

holding of life sustaining treatment (CPE5 .0027) .

McCann RM, Hall WJ and Groth-Juncker AG . Comfort care 9 .

for terminally ill patients: the appropriate use of nutrition and hydration . JAMA 1994; 274:1263-1266 .

Curran JJ .

10 . Patient’s Plan of Care: Goals and Treatment Options. Explanatory Guide for Health Care Professionals. Available at http://www .oag .state .md .us/Healthpol/PPOC_ explanatory_professionals_final .pdf

Dronabinol (Marinol) 2 .5 mg po BID or TID; titrate dose

-to patient -tolerance and desired effect . This is the active ingredient in marijuana, in oral form . Many patients com-plain of unwanted psychotropic effects of this drug . Medical marijuana, in states where it is legal, may be considered as well . This is not legal in Maryland or at the VA at this time (2010) .

A two-week trial of these agents is sufficient to determine

-their benefit . If no benefit is seen after 2 weeks, discontinue these pharmaceuticals .

Discussions with Family and Surrogates — Key Points An advance directive should be completed by patients be-1 .

fore, or at the earliest onset, of cognitive loss, at a time when patients are still deemed capable of making and commu-nicating decisions . Once completed, surrogates and physi-cians generally are legally obligated to follow the patient’s expressed wishes .

Once a medical determination has been made that adequate 2 .

oral nutritional intake to sustain life is not possible and there are no prior expressed wishes, all reasonable options must be discussed with families/surrogates . Present the medical data for and against tube feeding, citing benefits, burdens and alternatives .

The option of withholding/withdrawing feeding must be 3 .

done in a manner that minimizes guilt upon the family/ sur-rogate .

If available, review patient wishes expressed in an advance

-directive with family/surrogate; Note: if a patient has ex-pressed wishes not to have non-oral feeding/hydration in an advanced directive, emphasize to the surrogate(s) that they do not need to make the choice about withdrawal or with-holding as the choice has already been made by the patient; the decision by the surrogate is about honoring a previously made decision .

Inquire about patient and family religious or cultural values;

-Ask the family/surrogate, “what would (name) want if he/

-she could tell us?”

Give permission to withhold/withdraw feeding – families/

-surrogates will be looking to the physician for clear permis-sion and leadership to make this decipermis-sion .

Offer consultation input (Geriatrics, Neurology, Palliative

-care, Ethics, Chaplaincy, Psychology) .

Offer families/surrogates time to make a decision; suggest

-they contact their spiritual leader, friends or other family for further discussion .

Provide patient/family with education material .

-If a decision is made to begin non-oral feedings, establish a 4 .

time frame (e .g ., 4-8 weeks) for re-evaluation, to establish if the goals of feeding are being met (e .g ., weight gain, im-proved function) . Reassure families/surrogates that if goals are not being met, non-oral feeding can be discontinued . If a decision is made to discontinue/not begin non-oral feed-5 .

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Mitchell SL, Kiely DK, Lipsitz LA . Arch Intern Med. 1997;157:327-332 . Sanders DS et al . Am J Gastroenterology. 2000;95:1472-1475 . Starvation vs. Cachexia Starvation Cachexia Body weight 6 NC/6

Body cell mass 6 666

Body fat 666 66

Caloric intake 666 666

Total energy expenditure 66 6

Resting energy expenditure 666 55

Protein synthesis 666 5/6

Protein degradation 666 555

Serum insulin 666 555

Serum cortisol NC 55

NC = no change

Kotler DP . Ann Intern Med. 2000; 133:622-634 .

Cachexia annotated references

Deans C, Wigmore SJ . Systemic inflammation, cachexia and prognosis in patients with cancer . Current Opinion in Clinical Nutrition Metabolic Care. 2005;8:265-269 .

Reviews markers of inflammation and their relationship to ca-chexia, prognosis, and possible treatments in cancer patients . Fouladium M et al . Body composition and time course changes in regional distribution of fat and lean tissue in unselected cancer patients on palliative care – Correlations with food intake, metabolism, exercise capacity, and hormones . Cancer 2005;103:2189-2198 .

Detailed measurements and analyses of 311 cancer patients over time, discussing differences between cancer patients and other patients with cachexia .

Gordon JN, Green SR, Goggin PM . Cancer cachexia . QJ Med 2005;98:779-788 .

Review of what’s been tried for treatment of cancer cachexia, concluding that nothing really works yet…

Hammond L . Food at end of life . J Palliative Med 2007;10:997 . A one page patient/family handout of useful suggestions . Kotler DP . Cachexia (review) . Ann Intern Med 2000;133:622-634 .

The “classic” review of cachexia, still unsurpassed in 2010 . Loberg RD et al . The lethal phenotype of cancer: The mo-lecular basis of death due to malignancy . CA Cancer J Clin 2007;57:225-241 .

An excellent description of how cachexia is one of the lethal syndromes for cancer patients .

Manon SA et al . On our way to targeted therapy for cachexia in cancer? Curr Opin Oncol 2006;18:335-340 .

Are we on our way? Not really, or at least we haven’t gotten very far .

Skipworth RJE, Fearon KCH . The scientific rationale for optimizing nutritional support in cancer . Europ J Gastroenterol Hepatology 2007;19:371-377 .

Simple solutions to cachexia are unlikely to work: a multi-modality approach may be more effective .

Slaviero KA et al . Baseline nutritional assessment in advanced cancer patients receiving palliative chemotherapy . Nutrition and Cancer 2003;46:148-157 .

Detailed review of assessment tools for cancer patients, with rationale for use of C-reactive protein as surrogate marker of cachexia .

Suh SY, Ahn HY . A prospective study of C-reactive protein as a prognostic factor for survival time of terminally ill cancer patients . Support Care Cancer 2007;15:613-620 .

Elevated C-reactive protein predicts shorter life expectancy in advanced cancer .

Additional References

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harmful . American Hospice Foundation Web site . 2005 . Avail-able at http://www .americanhospice .org/index .php?option=com_ contentandtask=viewandid=48andItemid=8 .

Casarett D, Kapo J, Caplan A . Appropriate use of artificial nutri-tion and hydranutri-tion – fundamental principles and recommenda-tions . NEJM . 2005;353(24):2607-2612 .

Dy SM . Enteral and parenteral nutrition in terminally ill cancer patients: A review of the literature . Am J Hosp Palliat Care. 2006;23(5):369-377 .

Fainsinger RL . Non-oral hydration in palliative care . Fast Facts and Concepts. April 2005; 133 . Available at: http://www .eperc . mcw .edu/fastfact/ff_133 .htm .

Fainsinger RL . Non-oral hydration techniques in palliative care . Fast Facts and Concepts. April 2005; 134 . Available at: http:// www .eperc .mcw .edu/fastfact/ff_134 .htm .

Ganzini L . Artificial nutrition and hydration at the end-of-life: ethics and evidence . Palliat Support Care 2006 Jun;4(2):135-43 . Hallenbeck J . Tube Feed or Not Tube Feed? 2nd Edition . Fast Facts and Concepts. August 2005; 10 . Available at: http://www . eperc .mcw .edu/fastfact/ff_010 .htm .

Moynihan T, Kelly DG, Fisch MJ . To feed or not to feed: Is that the right question? J Clin Onc. 2005;23(26):6256-6259 .

Owens DA . Hydration in the terminally ill: A review of the evi-dence . J Hosp Palliat Nurs. May/June 2007;9(3):122-123 . Weissman DE . Swallow Studies, Tube Feeding, and the Death Spiral, 2nd Edition . Fast Facts and Concepts. October 2007; 84 . Available at: http://www .eperc .mcw .edu/fastfact/ff_084 .htm . Maryland LST Options Form

Instructions on Current Life-Sustaining Treatment Options (and the form) are available at http://www .oag .state .md .us/Healthpol/ LST%20Options%20Draft1%202007 .pdf

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Part 3: Evaluation Checklist Date: ____________________________________________

Learner name: _______________________________________________ Evaluator/Attending: _______________________________________

o Resident PGY Level: [ ] 1 [ ] 2 [ ] 3 [ ] 4 [ ] 5

o Fellowship Year: [ ] 1 [ ] 2 [ ] 3 [ ] 4 [ ] 5

Rotation Site: [ ] Inpatient Cancer Center [ ] Inpatient GIM [ ] Oncology Clinic [ ] Continuity GIM clinic [ ] Other Please rate the trainee’s competency/skills/knowledge/attitude using the following scales:

For competency/skills For knowledge and attitudes (e.g., Medical Knowledge) 4 = Competent to perform independently 4 = Superior

3 = Competent to perform with minimal supervision 3 = Satisfactory 2 = Competent to perform with close supervision / coaching 2 = Below average

1 = Needs further basic instruction 1 = Insufficient – needs further learning

n/o = not observed n/o = not observed

OBJECTIVES Patient Care

4o 3o 2o 1o n/oo Recognized cachexia syndromes, if appropriate, associated with terminal illnesses.

4o 3o 2o 1o n/oo Effectively managed conflicts between physician care recommendations for artificial nutrition and hydration

and requests for artificial feeding/hydration from the patient/proxy/family.

Overall Performance:

Cannot 1 to 3 4 to 6 7 to 9

Evaluate Unsatisfactory Satisfactory Superior

0 1 2 3 4 5 6 7 8 9

Medical Knowledge

4o 3o 2o 1o n/oo Discussed the benefits and burdens of appetite stimulants in terminally ill patients.

4o 3o 2o 1o n/oo Listed, in legal order, who can make decisions for a non-decisional patient.

Overall Performance:

Cannot 1 to 3 4 to 6 7 to 9

Evaluate Unsatisfactory Satisfactory Superior

0 1 2 3 4 5 6 7 8 9

Practice-Based Learning and Improvement

4o 3o 2o 1o n/oo Illustrated situations when it is appropriate to discuss withdrawal or withholding of artificial nutrition or hydration in terminally ill patients.

Overall Performance:

Cannot 1 to 3 4 to 6 7 to 9

Evaluate Unsatisfactory Satisfactory Superior

0 1 2 3 4 5 6 7 8 9

Professsionalism

4o 3o 2o 1o n/oo Partnered effectively and efficiently with allied health professionals when planning a discussion of with-holding or withdrawing artificial nutrition or hydration.

4o 3o 2o 1o n/oo Discussed the ethical and legal principles guiding use or non use of artificial nutrition and hydration in a terminally ill patient.

Overall Performance:

Cannot 1 to 3 4 to 6 7 to 9

Evaluate Unsatisfactory Satisfactory Superior

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Resident/Fellow strengths:

Resident/Fellow areas for improvement:

Overall impression: Did the Resident/Fellow demonstrate competency in a manner so as to do no harm?

Cannot 1 to 3 4 to 6 7 to 9

Evaluate Unsatisfactory Satisfactory Superior

0 1 2 3 4 5 6 7 8 9

Resident/Fellow self-evaluation of performance: May comment on any of the above checklist items or other reflections on

perfor-mance; perceived strengths, and need for improvement and learning.

__________________________________________

__________________________________________

Clinical Faculty Evaluator/Attending Resident/Fellow

__________________________________________

__________________________________________

Figure

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References

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