Medicine and Palliative Care

The Specialist in Medicine and Palliative Care must have gained theoretical, scientific and professional knowledge, both within and outside the hospital, in the field of assistance to patients in an advanced stage of illness with an uncertain or particularly unfortunate outcome. To reach this state of maturity, the specialist must follow a training course that allows him to know the natural history of chronic degenerative diseases and thus achieve full awareness of the clinical, diagnostic and therapeutic problems that characterize the path of the various pathologies, whether they are internal, oncological or of specialist relevance. He must be able to intervene in the treatment process of all the clinical pictures of the most common chronic diseases in the evolutionary and advanced stages, in the first person and through interprofessional and multidisciplinary confrontation in situations in which he is consulted by other specialists or by the general practitioner and within the palliative care team. In particular, it intervenes in the diagnostic and therapeutic phase in order to improve the patient's quality of life, in the communication process, in the socio-family, spiritual, psychological assessment, in the development of the care and treatment plan; he must be able to identify the patient's wishes and consider the ethical implications of the decision-making process. He/she must develop knowledge and skills in health management in order to optimize resources according to the principles and standards of quality, effectiveness, efficiency and acceptability of interventions; he must also have notions regarding epidemiological and clinical-therapeutic research applied to palliation; they must acquire notions of risk management and promote educational initiatives to develop a culture of health that integrates the concepts of chronicity and accompaniment to the terminal phases.

The student must have acquired satisfactory theoretical knowledge and professional competence in the clinical and instrumental diagnosis and treatment, even in emergency-urgency conditions, of the most common internal diseases, oncological pathologies, system pathologies that include diseases with chronic degenerative evolution such as pneumological, neurological, nephrology, cardiology, haematological, orthopaedic, gastroenterological, endocrine-metabolic, rheumatological, diseases induced by infectious processes, as well as conditions of developmental polymorbidity related to aging.

The student must acquire the fundamental knowledge of the pathophysiology of the various organs and systems, the theoretical and practical knowledge necessary for the recognition of diseases affecting the different systems of the body, the theoretical and practical knowledge of the main sectors of instrumental and laboratory diagnostics related to the aforementioned diseases, the acquisition of the ability to evaluate internal and specialist connections and influences. He must therefore be able to recognize the symptoms and clinical-functional signs with which diseases of various organs and systems manifest themselves, having acquired the fundamental diagnostic, therapeutic, psychological and ethical knowledge necessary for a global vision of the patient. To this end, the ability to clinically frame the patient on the basis of the anamnesis and physical examination must mature; develop critical and analytical diagnostic skills; become familiar with the main diagnostic procedures and laboratory-instrumental investigations; recognise and be able to deal with major medical emergencies; familiarize themselves with therapeutic resources in order to plan their optimal use and recognize their indications and contraindications, as well as the effects of interaction and possible iatrogenic accidents; acquire the fundamental notions relating to clinical research methodologies and pharmacological trials; know the fundamental problems related to prevention, public health and social medicine.

The resident must have acquired satisfactory theoretical knowledge and professional competence in the recognition and treatment, in emergency-urgency conditions, of the most common pathologies.

The resident must also progressively acquire the diagnostic and therapeutic skills necessary for the management and clinical management of complex patient conditions in all phases of chronic diseases with unfavourable evolution; the ability to communicate clearly and humanely with the patient and family members regarding informed consent, possible therapeutic support and clinical decisions for the control of symptoms also for accompaniment at the end of life; the ability to interact with other specialists and other health professionals; skills regarding health organization and clinical governance; knowledge of research and evidence-based medicine in the different fields of disciplines. He will therefore have to refine theoretical knowledge and professional competence in the. recognition and treatment of advanced stages of illness and end of life, especially with reference to the identification of the timely and progressive transition from active care to palliative care, with the ability to interact effectively with specialists in all phases of the above-mentioned pathologies, including the clinical conditions of incurability, having gained particular ability in the evaluation and treatment of the conditions characteristic of the advanced stages of these."

At the end of the Course, the Resident must have, at least:

• carried out assistance activities in Palliative Care Services in Hospice, in Home Palliative Care Units (UCP) and in hospitals, drawing up and countersigning at least 100 medical records of inpatient or outpatient patients personally followed; the records must show a complete physical examination that includes, among other things, the evaluation of the nutritional status;
• performed at least 50 interviews with the patient and family about the diagnosis and evolutionary phase of the underlying pathology, the prognosis, the therapeutic pathway, palliative treatment options, treatment objectives and end-of-life care and the organizational choice of the treatment plan;
• actively participated in the management, up to death, of at least 50 patients in the terminal phase of the disease;
• participated in the assessment and care and therapeutic planning of at least 100 patients who need Palliative Care in Hospital in the consultation and outpatient phases of palliative care;
• participated in the evaluation and setting up of the multidisciplinary therapeutic-care plan in Hospice, in the Home Palliative Care Unit and in hospital palliative care services;
• participated in the evaluation of the outcome of the treatment plans applied;
• organized one or more clinical audits to improve the quality of care

For the typology of the School of Medicine and Palliative Care (divided into four years of the course) the educational objectives are as follows:

Basic learning objectives The student must deepen and update his knowledge on the evolution of the most common complex and advanced chronic conditions, on the pathophysiological correlations between the functional alteration of the various organs and systems and the clinical syndromes and related symptoms as well as on the knowledge of guidelines for palliative pharmacological treatment. In particular, he must learn the methods of assessing the quality of life, the knowledge of the pathophysiology of pain, the identification and interpretation of the health needs of individuals and their families, and the appropriateness and effectiveness of care interventions, the acquisition of listening, relationship and interpersonal communication skills; the acquisition of the principles of medical ethics and clinical bioethics, the ability to have a theoretical and operational approach aimed at interprofessional work.

General training objectives The student must acquire epidemiological, clinical, psychological, ethical and managerial knowledge and the methodology of clinical reasoning for a global and unitary approach to the solution of complex health problems; the development of clinical reasoning oriented towards analysis "by problems" and their solution; the knowledge of the short-term prognosis of the various pathologies and clinical syndromes; the maturation of critical and analytical diagnostic skills (diagnosis by positive, etiological and differential elements), setting up and personally verifying the therapeutic process; the deepening of knowledge relating to drugs both for pharmacological characteristics and for indications and contraindications, interactions; the maturation of the critical capacity necessary for the application, in the individual case, of the results of scientific research; the ability to apply the methodology of clinical, experimental and therapeutic research, and epidemiological research; knowledge of the correct use of resources and budget and monitoring of the quality of care; must acquire the listening and relationship skills necessary to communicate effectively with patients, family members and other professionals involved in the management of the patient; they must learn the ethical principles involved in the medical decision-making process with particular regard to the phases that characterize the end of life. Educational objectives of the type of School

The educational aims of the Postgraduate School are divided into the following areas:

1. palliative care and palliative medicine based on a knowledge of the trajectories of diseases that result in a chronic, degenerative and evolutionary process;

2. principles, definitions, clinical, regulatory aspects, organizational models of palliative care and palliative medicine; 3. control of pain and symptoms;

4. psychosocial and spiritual aspects of care;

5. ethical and legal aspects;

6. communication;

7. teamwork;

8. Management/Business Intelligence.

At the end of the Course, the Resident must:

• know the natural history of the main diseases with chronic and degenerative evolution;
• know the definition and fundamental principles of palliative medicine and Palliative Care (quality of life, early and simultaneous palliative care and end-of-life care);
• to be able to correctly identify the early need for palliative care by framing it in the diagnostic and therapeutic pathway of the various chronic developmental diseases;
• know how to integrate their knowledge with that of specialists in the various chronic evolutionary diseases in order to plan personalized diagnostic and therapeutic paths on the evolution of the underlying pathology;
• know how to apply their knowledge and skills to terminal situations even in acute and emergency situations;
• know the clinical criteria that allow the indication to be placed on a palliative care pathway, also with reference to those for eligibility for the different care settings;
• know the tools for assessing and measuring specific needs for palliative care, in particular relevant symptoms and clinical pictures;
• know how to use prognostic assessment tools and tools to identify patients in relation to the trajectories of different diseases;
• know how to identify and apply digital health tools through the use of 'mobile' devices and apps in order to ensure the transition and sharing of information through the management of ICT platforms;
• know how to use, through digitized systems, multidimensional assessment tools;
• know how to use 'integrated business intelligence' applications, which allow the measurement of assistance, performance and economic indicators (Big data);
• know how to diagnose and treat pain and other symptoms, complications and emergencies of all the most relevant pathologies in the advanced stages;
• be able to recognize refractory symptoms in order to make the indication and perform palliative sedation; The Minister of University and Research in agreement with the Minister of Health
• be able to identify the complex psychological, social, existential and spiritual needs of patients;
• know how to manage informed consent, Advance Treatment Provisions (DAT) and Shared Care Planning (PCC);
• know the fundamentals of the organization of Palliative Care services according to the regulations and know how to activate Palliative Care services in the Region;
• to know the regional organization of the Palliative Care Network; - know how to identify and enhance the factors that favor teamwork;
• to be able to recognize the psychological, social, existential and spiritual needs of the patient and the family, as well as the possible psychopathological frameworks and the different attitudes and emotional responses to incurable illness and the dying process;
• know how to communicate and establish a relationship with the patient and the family, recognizing the factors that promote empathic and personalized communication even in the management of "difficult" communications;
• to be able to integrate into clinical and care practice a multidimensional approach, not only clinical, exemplified by the concept of "total pain" by enhancing the significant passages of the patient's biography, human and personal story, as fundamental components in the process of accompaniment;
• be able to recognise the bioethical implications in the field of Palliative Care, in particular with regard to patient information and involvement in therapeutic decisions and the different organisational choices in the care plan;
• know the fundamentals of clinical and epidemiological research in palliative care and its application to evidence-based care and care.

Related, integrative and interdisciplinary objectives The student must acquire the ability to improve the quality of life of the assisted person and his/her family through the selection of resources, the activation of those available and the harmonization of the interdisciplinary interventions of the team; the ability to work collaboratively and effectively with the entire team, in compliance with quality care standards; the ability to activate the various structures in which the palliative care network is divided, as well as the methods to ensure integration between residential care facilities and home care units; the ability to actively promote one's own well-being and that of the team, through risk assessment and the adoption of prevention and protection measures; the ability to apply epistemological and methodological skills and advanced techniques to design and conduct qualitative and quantitative research in the palliative field.