Second Year Curriculum

Course Directors: G. J. Caranasos, M.D. and Ray Moseley, Ph.D.

Second Semester

Essentials of Patient Care - Introduction to Clinical Medicine (Dr. Caranasos)

Geriatric Assessment - Health and Illness in the Elderly
Geriatric Syndromes
Urinary Incontinence
Dementia/Delirium
Gait and Balance and Falls
Infections
Sleep Disorders
Polypharmacy
Rehabilitation
Geriatric Principles of Extended Care - Nursing Homes, Hospice, ACLFs
Interviewing Demented Patients in Nursing Homes
Group Discussions of Case Material

Ethical and Legal Issues in Medical Practice (Dr. Moseley)

Course Faculty:

Bill Allen, J.D. A1-154 846-1097
Ray Moseley, Ph.D. A1-151 846-1()97
James Wagner, Ph.D. Shands 1145 395-0224
Medical Ethics, Law and the Humanities, Department of Community Health and Family Medicine

Course Texts and Readings:

The required texts for this course are Contemporary Issues in Bioethics, 4th ed., by Beauchamp and Walters and OM Doctoring, editors Richard Reynolds and John Stone. Bioethics is available in the Health Center Bookstore. Additional required readings are on reserve in the Medical Ethics, Law and the Humanities Library.

Lecture: Ethical and Legal Issues at the End of Life

Ray Moseley, Ph.D. and Bill Allen, J.D. Program in Medical Ethics, Law and the Humanities Department of Community Health and Family Medicine

Readings:

Bioethics, pp. 351-380, 383-4()2

*In re: Guardianship of Estelle M. Browning, State of Flolida vs Doria F. Herbert, Supreme Court of Florida, #74, 174, September 13, 199

Group Session: Ethical and Legal Issues at the End of Life

Group A - Thursday, February, 2:10-4:00 p.m.
Group B - Friday, February, 2:10-4:00 p.m.

Readings:

Thomas D. "Do Not Go Gentle Into that Good Night," in On Doctoring, p. 215.
Williams M. "A Day in the Death," in On Doctoring, p. 317.
*Letter from Deborah Scalise to her father's physician.
*"Health Care Advance Directives." Summary of Florida Statute 765.01-765.15.
*Shands Hospital Policy, "Patient Self-Determination,'' and "Withholding or Withdrawing Life-Sustaining Measures for Adults and Minors," and "Cardiopulmonary Resuscitation.
" *Nolan E. "One Cold Beer," JAMA, February 21, 1986, Vol. 255, No. 7, p. 908.

Key Ethical/Legal Issues:

To what extent do the principles of autonomy and beneficence Support a patient's right to refuse medical treatment?

Who should decide what is in the patient's "best interest" in regard to withdrawal of life-sustaining treatment?

Key Terms/Distinctions:

Advance Medical Directive
"Best Interests" Standard
Brain death
Browning case
Comfort care
Competence/capacity
Christian Scientist
Cruzan case
Cure/care
Doctrine/principle of double effect
Durable Power of Attorney
Dying process
Florida Statute, Chapter 765, "Health Care Advance Directives"
Hospice
Hydration and nutrition
Jehovah's Witness
Ordinary/extraordinary (artificial, heroic) treatments
Patient Self:determination Act
Permanent vegetative state (PVS)
Proxy
Poor prognosis
Quality of life (QOL)
Refusal of treatment
Substituted judgment
Surrogate
Terminal illness
Withhold/withdrawing

Lecture: The Ethical and Legal Problems of Euthanasia and Assisted Suicide and Medical Futility

Bill Allen, J.D. Medical Ethics, Law and the Humanities

February, 2:10-3:00 p.m., C-1-15

Readings:

Bioethics, pp. 431 -449, 465-471, 479-482
Angelou M "The Last Decision," in On Doctoring, p. 291
Seizer R. "Mercy," in On Doctoring, p. 275.
Stone J. "Death," On Doctoring, p. 351.
Williams W.C., "The Last Words of My English Grandmother," On Doctoring, pp. 81-82.
*"It's Over Debbie," JAMA January 8, 1988, 259(2), p. 272, and editorials and letters.

Key Terms/Distinctions:

Active/passive euthanasia
Assisted suicide
Doctrine/principle of double effect
Do not resuscitate orders (DNR)
Euthanasia
Medical futility
"Slow Code"
Voluntary/involuntary euthanasia

Competency expectations upon completion of second year in Geriatrics:

• Human Relationships and Communications: As delineated for year one.
• Professional Behavior:
  • Treats people respectfully.
  • Demonstrates a priority for the patient's well-being over sell-interest (altruistic behavior), (e.g., willingness to take on managed care's unwillingness to pay for a needed procedure).
  • Appropriately overcomes or compensates for personal prejudices in the delivery of health care.
  • Demonstrates an appropriate self-assessment of personal values, knowledge and ability.
  • Appropriately responds to legal aspects of medicine (competency, involuntary commitment, liability fears, etc.).
  • Appropriately demonstrates an understanding of patient's rights (legal and moral) and responds appropriately when these rights are exercised (refusal of treatment, access to medical records, etc.).
  • Appropriately demonstrates understanding of ethics committees and the ethics committee consultation process.
  • Appropriately responds to the impact of social and economic factors on the delivery of health care (e.g. does not give substandard care based on patient's ability to pay, does not discriminate based on age).
  • Demonstrates the ability to develop a lair allocation of scarce medical resources, on the microallocation level (e g. how to Fairly allocate physician time).
  • Demonstrates the ability to address the ethical issues raised by medical research in the delivery of health care (patient who is considering an experimental clinical trial for cancer).
  • Demonstrates the ability to resolve conflicts between physician's personal moral convictions that conflict with the delivery of medical treatment/procedures to the patient (patient request for abortion, birth control, etc.)
  • Demonstrates an understanding and sensitivity of the patient's culture/ethnicity in regard to effective health care delivery.
  • Demonstrates ability to address satisfactorily ethical and legal conflicts between pregnant woman and best medical interests of her fetus (e.g. prenatal drug testing, compelled medical treatment of woman).
• Diagnostic:
  • Demonstrates ability to perform a comprehensive physical examination.
  • Demonstrates ability to perform a problem focused physical examination.
  • Demonstrates ability to obtain a comprehensive patient history. Demonstrates ability to obtain a focused patient history.

Appendix to Second-Year Curriculum

Objectives for Geriatric Syndromes

Dementia in the Elderly. The student should be able to:

1. Define dementia.
2. Differentiate dementia from delirium and depression.
3. Understand that dementia is a clinical syndrome with many etiologies.
4. List the important elements of the history, physical examination, and laboratory evaluation which should be obtained when evaluating a patient with dementia.
5. Differentiate Alzheimer's disease from other cases of dementia.
6. Describe the basic guidelines for the symptomatic management of agitation, wandering, anxiety, and insomnia in demented patients.
7. Describe the therapeutic effects and side effects of the new treatments of Alzheimer's disease.
8. Be familiar with current research on the causes and treatment of Alzheimer's disease.

Falls in the Elderly. The student should be able to:

1. Describe the epidemiology of falls.
2. Discuss the complications of falling.
3. Understand the age-related changes that predispose falling.
4. List the pathological processes and medications that predispose falling.
5. List the environmental factors that predispose Palling.
6. Describe the evaluation/prevention strategies both for those who have fallen and those who are at fall risk.

Medication Use in the Elderly. The student should be able to:

1. Define pharmacokinetics.
2. Define pharmacodynamics.
3. List significant age-related pharmacokinetic changes.
4. Discuss the principles of age-related pharmacodynamic changes.
5. Describe the utility and pitfalls of predictive formulas used to calculate creatinine clearance.
6. Give strategies that will reduce the likelihood of adverse drug events in the elderly.

Clinical Health Maintenance for the Elderly. The student should be able to:

1. Describe required immunization protocols for the elderly.
2. List specific cancer screening guidelines for the elderly and explain the rationale for their implementation.
3. Explain tuberculosis screening procedures.
4. List certain disorders which are common among the elderly that should he screened for.

Osteoporosis. The student should be able to:

1. Understand the difference between osteoporosis, osteomalacia, and osteopenia.
2. Know the secondary causes of osteoporosis.
3. Know the risk factors for the development of osteoporotic fractures.
4. Understand the applications and limitations of hone densitometry.
5. Understand the properties of available treatment options.

Peri-Operative Considerations In The Elderly Surgical Patient. The student should be able to:

1. Assess Factors which may increase the risk of peri-operative complications and mortality in the elderly surgical patient.
2. Appreciate that the risk of undesirable outcomes in the elderly surgical patient is generally due to a higher burden of disease in this population rather than to chronological age alone and that many surgical procedures may be very sale even in the very old.
3. Define strategies for the pre-operative diagnosis and subsequent management of the high-risk geriatric patient.
4. Recognize age-related physiological alterations responsible far altered responses to anesthetic and analgesic agents.
5. Understand the diagnosis and management of delirium, one of the "geriatric" syndromes commonly presenting in the post-operative elderly patient.
6. Appreciate the possibility of altered clinical presentations of "non-geriatric" post-operative complications in the elderly patient.

Physical Changes in Aging. The student should be able to:

1. Recognize the physiological aspects of normal aging.
2. Differentiate normal age-related changes tram those which require further evaluation.
3. Become familiar with the physical exam of the elderly and normal age-related changes.

Pressure Sores. The student should be able to:

1. Appreciate the link between pathophysiology and clinical presentation
. 2. Identify individuals at high risk for developing pressure sores.
3. Describe clinical staging of pressure sores.
4. Understand preventive strategies in high-risk individuals.
5. Outline management

Rehabilitation of the Geriatric Patient. The student should be able to:

1. Differentiate between impairment, handicap, and disability.
2. Appreciate the significance of a comprehensive functional assessment.
3. Understand the role of rehabilitation professionals in the delivery of rehabilitation services.
4. Describe the utility of ambulation aids.
5. Structure a problem-oriented rehabilitation approach to disability.

Urinary Incontinence. The student should be able to:

1. List the different etiologies of urinary incontinence.
2. Explain how to evaluate an incontinent patient.
3. Discuss the various treatment modalities of urinary incontinence.

Illness in the Elderly. The student should be able to:

1. Provide examples of physiological changes with age that may predispose the elderly to disease.
2. Describe the factors that lead to an altered presentation of disease in the elderly.
3. Provide examples of atypical disease presentations often seen in the elderly.
4. Describe the issues that underlie the need far a team approach in the elderly.

Sensory Changes in Aging. The student should be able to:

1. Understand that normal aging is associated with sensory losses that can constitute risk factors for illness and injury.
2. Distinguish the sensory losses that accompany normal aging from those clearly related to disease processes.
3. List age-associated changes in vision and describe the basic characteristics of visual disorders that commonly occur in the elderly.
4. Describe the prevalence, type of healing impairment, and general management of presbycusis in the elderly.
5. Describe the effect of age on taste and smell.
6. Recognize that most sensory losses can be corrected and need not lead to the sensory deprivation and isolation that often occurs with aging.

Palliative Care. The student should be able to:

1. Define palliative care.
2. Understand the Medicare hospice benefit.
3. Understand the basic principles of prognostication.
4. Understand the basic management of common non-pain symptoms at the end of life.
5. Be cognizant of the issues regarding artificial nutrition and hydration at the end of life.
6. Understand the clinician's role in the bereavement process.