DNB Palliative Medicine or Diplomate
of National Board in Palliative Medicine also known as DNB in Palliative
Medicine is a Postgraduate level course for doctors in India that is done by them
after completion of their MBBS. The duration of this postgraduate course is 3
years, and it focuses on the study of various concepts
related to the field of study and management of patients living with active, progressive, and far-advanced diseases. Further focus on providing relief from pain.

The course is a full-time course pursued at various accredited
institutes/hospitals across the country. Some of the top accredited
institutes/hospitals offering this course are- Aster CMI Hospital- Karnataka, Cancer Institute (WIA)- Tamil Nadu, Indo-American Cancer Institute and Research Centre- Telangana, and more.

Admission to this course is done through the NEET PG Entrance exam
conducted by the National Board of Examinations, followed by counselling based
on the scores of the exam that is conducted by DGHS/MCC/State
Authorities.

The fee for
pursuing DNB (Palliative Medicine) from accredited institutes/hospitals is Rs.
125000 per Year.

After completion of their respective course, doctors can either join the
job market or pursue a super-specialization course where DNB Palliative
Medicine is a feeder qualification. Candidates can take reputed jobs at
positions as Senior residents, Junior Consultants, Consultants etc. with an
approximate salary range of Rs. 3 Lakh to Rs. 8 Lakh per annum.

DNB is
equivalent to MD/MS/DM/MCh degrees awarded respectively in medical and surgical
super specialties. The
list of recognized qualifications awarded by the Board in various broad and
super specialties as approved by the Government of India are included in the
first schedule of the Indian Medical Council Act, 1956.

The Diplomate
of National Board in broad-specialty qualifications and super specialty
qualifications when granted in a medical institution with the attached hospital
or in a hospital with the strength of five hundred or more beds, by the
National Board of Examinations, shall be equivalent in all respects to the
corresponding postgraduate qualification and the super-specialty qualification
granted under the Act, but in all other cases, senior residency in a medical
college for an additional period of one year shall be required for such
qualification to be equivalent for the purposes of teaching also.

What is DNB in Palliative
Medicine?

Diplomate of National Board in Palliative
Medicine, also known as DNB (Palliative Medicine) or DNB in Palliative Medicine is a three-year postgraduate programme that
candidates can pursue after completing MBBS.

Palliative Medicine is the branch of medical
science that involves the study and management
of patients living with active, progressive, far-advanced diseases.

The National
Board of Examinations (NBE) has released a curriculum for DNB in Palliative
Medicine.

The curriculum governs the education and training of DNBs in Palliative Medicine.

PG education intends to create
specialists who can contribute to high-quality health care and advances in
science through research and training.

The required training done by a
postgraduate specialist in the field of Palliative
Medicine would help the specialist recognize the community’s health needs.
The student should be competent to handle medical problems effectively and
should be aware of the recent advances in their speciality.

The candidate should be a highly
competent specialist in Palliative
Medicine possessing a broad range
of skills that will enable her/him to practice Palliative Medicine independently. The PG candidate should also
acquire the basic skills in the teaching medical/para-medical students.

The candidate is also expected to
know the principles of research methodology and modes of the consulting
library. The candidate should regularly attend conferences, workshops, and CMEs
to upgrade her/ his knowledge.

Course Highlights

Here are some of the course highlights of DNB in Palliative Medicine

Name of Course

DNB in Palliative
Medicine

Level

Postgraduate

Duration of Course

Three years

Course Mode

Full Time

Minimum Academic Requirement

MBBS degree obtained from any
college/university recognized by the Medical Council of India (now NMC)

Admission Process / Entrance Process /
Entrance Modalities

Entrance Exam (NEET PG)

Course Fees

Rs. 125000 per Year

Average Salary

Rs. 3 Lakh to Rs. 8 Lakh per
annum

Eligibility Criteria

The eligibility
criteria for DNB in Palliative Medicine
are defined as the set of rules or minimum prerequisites that aspirants must
meet in order to be eligible for admission, which includes:

Candidates must
be in possession of an undergraduate MBBS degree from any college/university
recognized by the Medical Council of India (MCI) now NMC.

Candidates should have done a compulsory rotating
internship of one year in a teaching institution or other institution which is
recognized by the Medical Council of India (MCI) now NMC.

The candidate must have obtained permanent
registration of any State Medical Council to be eligible for admission.

The medical college’s recognition cut-off
dates for the MBBS Degree courses and compulsory rotatory Internship shall be as
prescribed by the Medical Council of India (now NMC).

Candidates who have passed the final
examination, leading to the award of a Post Graduate Degree (MD/MS) from an
Indian University, which is duly recognized as per provisions of the National
Medical Commission (NMC) Act, 2019 and the first schedule of the IMC Act can
apply for the DNB Final examination in the same broad specialty.

Admission Process

The admission process contains a few steps to
be followed in order by the candidates for admission to DNB in Palliative Medicine. Candidates can view the complete
admission process for DNB in Palliative
Medicine mentioned below:

The NEET PG or National Eligibility Entrance
Test for Post Graduate is a national-level master’s level examination conducted
by the NBE for admission to MD/MS/PG Diploma Courses.The
requirement of eligibility criteria for participation in counselling towards PG
seat allotment conducted by the concerned counselling authority shall be in
lieu of the Post Graduate Medical Education Regulations (as per the latest
amendment) notified by the MCI (now NMC) with prior approval of MoHFW.

S.No.

Category

Eligibility Criteria

1.

General

50th Percentile

2.

SC/ST/OBC (Including PWD of SC/ST/OBC)

40th Percentile

3.

UR PWD

45th Percentile

Fees Structure

The fee structure for DNB in Palliative Medicine varies from
accredited institute/hospital to hospital. The fee is generally less for
Government Institutes and more for private institutes. The average fee structure for DNB in Palliative Medicine is Rs. 125000 per Year.

Colleges offering DNB in Palliative Medicine

Various accredited
institutes/hospitals across India offer courses for pursuing DNB (Palliative Medicine).

As per the National Board of
Examinations website, the following accredited institutes/hospitals are
offering DNB (Palliative Medicine)
courses for the academic year 2022-23.

Hospital/Institute

Specialty

No. of
Accredited Seat(s)
(Broad/Super/Fellowship)

Aster CMI
Hospital
#43/2, New
Airport Road, NH – 7, Sahakara Nagar, Hebbal, Bangalore
Karnataka-560092

Palliative
Medicine

2

Cancer Institute
(WIA)
No:38, Sardar
Patel Road, Adyar, Chennai
Tamil
Nadu-600036

Palliative
Medicine

2

Indo-American
Cancer Institute and Research Centre
Road No.14,
Banjara Hills, Hyderabad
Telangana-500034

Palliative
Medicine

2

Max Super
Specialty Hospital
1,2, Press
Enclave Road, Saket,
Delhi-110017

Palliative
Medicine

1

MNJ Institute of
Oncology and Cancer Regional Center
Red Hills, Lakdi
Ka Oil Hyderabad
Telangana-500004

Palliative
Medicine

2

Sir Ganga Ram
Hospital
Rajinder Nagar,
New Delhi
Delhi-110060

Palliative
Medicine

2

Syllabus

A DNB
in Palliative Medicine is a three years specialization course which
provides training in the stream of Palliative
Medicine.

The course
content for DNB in Palliative Medicine is given in the NBE Curriculum released by National Board of
Examinations, which can be assessed through the link mentioned below:

Post-graduate Trainee Resident pursuing DNB (Palliative Medicine) course is expected to have in-depth knowledge of following subject topics. [CD=Cognitive Domain]

Section Cd1: Introduction To Palliative Medicine

Sl. No

Topic

Essentials

Cd1.1 History Of Palliative Medicine

1.1.1

History of Palliative Medicine

• Ancient history of hospice care

• Dame Dr. Cicely Saunders and St. Christopherzs Hospice History and philosophy of Hospice movement

• Modern Hospice movement and evolution of .palliative care

• Evolution of Palliative Medicine

• History of Indian Palliative Care movement

Cd1.2 Principles of Palliative Medicine

1.2.1

Principles of Palliative Medicine 1

• Definitions (Palliative Care, Palliative Approach, Palliative Procedure, Generalist and Specialist Palliative Care)

• Illness trajectories and stages

• Understanding primary palliative care

• Estimating the Palliative Care need

• Cardinal concepts underlying the philosophy of Palliative Medicine

• WHO Principles of Palliative Care

• Holistic Care

1.2.2

Principles of Palliative Medicine 2

• Principle 1: Unit of care includes patient and his

/ her family

• Principle 2: Symptoms must be routinely assessed and managed

• Principle 3: Decisions regarding medical treatments must be made in an Ethical Manner

• Principle 4: Palliative Care is provided through an Interdisciplinary Team

• Principle 5: Palliative Care coordinates and provides for continuity of care

• Principle 6: Dying is a normal part of Life, and Quality of Life is a central clinical goal

• Principle 7: Palliative Care attends to Spiritual Aspects of patient and family distress and well-being

• Principle 8: Palliative Care neither hastens death nor prolongs dying

• Principle 9: Palliative Care extends bereavement support to patientsz families

• Principle 10: Palliative Care preserves and enhances the well‐being of clinical and support staff and volunteers

• Principle 11: Palliative Care engages in continuous Quality Improvement and research efforts

• Principle 12: Palliative Care advocates for patients and families and advances Public Policy to improve access to needed services and Quality of Care

CD1.3 SPECIALITY OF PALLIATIVEMEDICINE

1.3.1

Specialty of Palliative Medicine

• Levels of Care (Level 1-3)

• Development of Palliative Medicine Specialty

• Core competencies of a Palliative Medicine Physician

• Specialist Palliative Medicine Service

• CanMEDS Physician Competency Framework

• How to avoid downsides involved in specialist training

CD1.4 MULTIDISCIPLINARY TEAM

1.4.1

Multidisciplinary team 1

• Concept of Shared Care

• Multidisciplinary and Interdisciplinary team

• Role of a nurse in palliative care

• Role of a medical social worker in palliative care

• Role of occupational and physiotherapist in palliative care

• Role of Consultant Psychiatrist / Clinical Psychologist / Counselor in palliative care

• Role of nutritionist in palliative care

1.4.2

Multidisciplinary team 2

• Role of wound and stoma therapist in palliative care

• Role of speech and language specialist

• Role of volunteer in palliative care

• Role of chaplain and spiritual care person in palliative care

• Role of clinical pharmacist in palliative care

• Role of music therapist / art therapist / play therapist

• Role of yoga and complementary and alternative medicine specialist

CD1.5 MODELS OF PALLIATIVE CARE DELIVERY

1.5.1

Models of Palliative Care Delivery 1

• Stjernswärdzs Palliative Care for all Model

• Early Palliative Care

• Acute Palliative Care

• Integrated model

• Simultaneous and shared care model

(Description of model, mode of service delivery, advantages and disadvantages, evidence in literature)

1.5.2

Models of Palliative Care Delivery 2

• In-patient palliative care unit

• Hospice (Free standing unit)

• Hospital palliative care team (consultation liaison service)

• Community palliative care service (Home based palliative care)

• Out-patient palliative care unit

• Day palliative care unit

(Team composition, scope of service, skills, staffing, infrastructure, benefits, and disadvantages)

CD1.6 RESEARCH IN PALLIATIVE

MEDICINE

1.6.1

Research in Palliative Medicine 1

• Scope of research in Palliative Medicine

• Ethics of research in Palliative Medicine

• Barriers for research in Palliative Medicine

• Evidence based Palliative Medicine (Oxford CEBM levels of evidence, obtaining evidence, developing a citation database for

review, Judging the quality of trials, Judging the quality of review, Critical evaluation of a RCT and systematic review)

• Conducting a clinical trial in Palliative Medicine

1.6.2

Research in Palliative Medicine 2

• Writing a research protocol in Palliative Medicine

(Identifying the research area, defining the clinical problem, literature review, formulating the research question, defining objectives and patient population, appropriate study design, methodology, outcomes to be measured, statistical consideration, interpretation of results and arriving at conclusion)

• Qualitative research in Palliative Medicine Psycho-

• Social research in Palliative Medicine

CD1.7 SERVICE AND RESEARCH INSTRUMENTS USED IN PALLIATIVE MEDICINE

1.7.1

Tools / Instruments 1

• Tools / instruments measuring palliative care need

• Broad multi-symptom assessment instruments

• Performance status instruments

• Pain assessment instruments

• Instruments used to measure dyspnea

• Instrument used to measure fatigue

• Instruments measuring delirium

• Instruments used for assessment of anxiety

• Instruments used for measuring depression

1.7.2

Tools/Instruments 2

• Instruments measuring distress

• Instruments measuring spiritual and existential distress

• Instruments measuring coping and adaptation

• Instruments measuring social issues

• Instruments measuring caregiving issues

• Instruments measuring family issues

• Instruments measuring communication and satisfaction with care

• Instruments measuring sexuality and intimacy

• Instruments measuring pediatric aspects of advanced illness

CD1.8 ADVOCACY IN PALLIATIVE MEDICINE

1.8.1

Advocacy

• Policy Advocacy (Advocating for Institutional, State / National palliative care Policy)

• Capacity Building Advocacy (Advocacy for resources / funds to develop infrastructure needed for palliative care provision)

• Drug Availability Advocacy (Advocacy for improving access to pain and symptom control drugs – Essential Medication List)

• Education Related Advocacy

CD1.9 HEALTH POLICY AND PROGRAMS IN PALLIATIVE MEDICINE

1.9.1

Policy, Programs and Regulations

• Maharashtra and Kerala State Palliative Care Policy

• WHO Palliative Care Collaborating Centers and their activities

• Network neighborhood in Palliative Care

• National Palliative Care strategy for India

• Narcotic Drugs and Psychotropic Substance (NDPS) Act and its amendments

• Living will, Limiting life-sustaining treatment and Advanced Directives

CD1.10 QUALITY AND STANDARDS IN PALLIATIVE MEDICINE

1.10.1

Quality and Standards

• Quality and Standards in Palliative Medicine

• Classification and Types of Standards

• Country specific International Standards for

• Palliative Care

• End of Life Care Standards

• The Gold Standards Framework

• Clinical Practice Guidelines as applicable to Palliative Care

SECTION CD2: PALLIATIVE PHARMACOLOGY

CD2.1 PAIN PHARMACOLOGY

2.1.1

Non-steroidal anti- inflammatory drugs

• Cyclo-oxygenase (COX) pathway

• Classification (Classification based on COX, Efficacy, Potency)

• Pharmacokinetics

• Type A and Type B reactions NSAIDS and organ system (Renal,

Hepatic, Cardiovascular, Gastrointestinal, Lung,

Platelets, Bone, Genitourinary)

• Individual pharmacology of commonly used NSAIDs (Aspirin, Diclofenac, Paracetamol, Ibuprofen, Ketorolac, Oxicams, Etorocoxib)

• Rational NSAID prescription

Safe NSAID prescription

2.1.2

Opioids 1

• Opioidzs definitions

• Opioid receptors

• Opioid classification (Chemical and Receptor based classification)

• Opioid metabolism and metabolites

• Pharmacokinetics

• Opioid use in renal and hepatic impairment

• Common adverse effects of opioids and its management

• Systemic effects of long-term opioid use (opioid toxicity – identification and management)

• Opioids induced respiratory depression

• Opioids induced hyperalgesia

2.1.3

Opioids 2

• Opioid potency and conversion tables

• Opioid rotation

• Individual pharmacology of weak opioids (Codeine, Tramadol, Tapentadol,

Dextropropoxyphene)

• Individual pharmacology of strong opioids (Morphine, Fentanyl, Buprenorphine,Oxycodone, Hydromorphone)

• Initiating a patient on strong opioids and titration of dose

• Using strong opioids – Instructions to patients

and caregivers

2.1.4

Adjuvant Analgesics 1 (Adjuvants used in neuropathic pain)

• Anti-depressants (TCAs and SSRIs)

• Anti-epileptics

• Anti-arrhythmic (Na Channel Blockers)

• NMDA Receptor antagonists

• K Channel openers

• Drugs causing activation of GABA inhibitory and Glutamate excitatory system

• Corticosteroids

• Neuropathic Pain Step Ladder

2.1.5

Adjuvant Analgesics 2

• Adjuvant analgesics used in bone pain (Dexamethasone, Calcitonin, Bisphosphonates)

• Adjuvant analgesics used in GI pain (Hyoscine, Dicyclomine, Octreotide)

• Adjuvant analgesics used in genitourinary pain (Oxybutynin, Tolterodine, Solifenacin, Phenazopyridine, Propantheline, Tamsulosin, Flavoxate)

• Adjuvants in myofacial pain and muscle spasms (Baclofen, Flupirtine, Eperisone, Tolperisone, Thiocolchicoside)

CD 2.2 PHARMACOLOGY OF DRUGS USED IN NAUSEA, VOMITING, CONSTIPATION

2.2.1

Nausea and Vomiting 1

• Physiology of nausea and vomiting

• Emesis pathway

• Physiology of vomiting centers

• Receptors and neurotransmitters involved in Nausea and Vomiting

• Classification of anti-emetics (Central and GIT)

• Receptor sites and affinities of anti- emetics

• Classification of prokinetics based on receptor action

• Pharmacological management of chemotherapy and radiotherapy induced

nausea and vomiting.

2.2.2

Nausea and Vomiting 2

• Detailed pharmacology of individual drugs used in nausea and vomiting (Metoclopramide, Domperidone, 5HT3 antagonists)

• Anti-histaminic Anti-muscarinic drugs in nausea and vomiting

• Psychotropic drugs in nausea and vomiting

• Miscellaneous drugs in nausea and vomiting (Corticosteroids, Benzodiazepines, Cannabinoids, NK receptor antagonists)

2.2.3

Constipation

• Classification of aperients (Laxatives)

• Detailed pharmacology of commonly used drugs (Docusate, Bisacodyl, Lactulose, Macrogol, Senna, Magnesium compounds, Methyl Naltrexone)

• Rectal products (Suppositories, Micro and Standard Enema)

• Pharmacological management of opioid induced constipation

• Pharmacological management of constipation in paraplegia/quadriplegia

• Common drugs used in diarrhea.

CD2.3 CARDIOVASCULAR, RESPIRATORY AND CNS DRUGS IN PALLIATIVE CARE

2.3.1

Cardiovascular

• Diuretics

• Optimizing and stopping cardiovascular drugs in palliative phaseof illness trajectory

• Pharmacological management of cancer thrombosis, deep venous thrombosis and pulmonary embolism

2.3.2

Respiratory

• Oxygen and intermittent / long term oxygen therapy in palliative care / oxygen delivery systems

• Bronchodilators (oral / parenteral / inhaled)

• Drugs used in management of dyspnea

• Drugs used in management of cough

• Drugs used in management of respiratory secretions

2.3.3

CNS

(Anxiolytics, Anti- depressants and Anti- psychotics)

• Benzodiazepines in palliative care practice (classification, pharmacology of individual drugs, rational usage)

• Prescribing anti-depressants in palliative care practice (commonly used drugs and their pharmacology)

• Drugs used in delirium (typical and atypical anti-psychotics)

• Drugs used in managing terminal restlessness (step ladder and pharmacology of drugs used in terminal sedation)

CD2.4 TOPICAL AGENTS USED IN PALLIATIVE MEDICINE

2.4.1

Topical Agents

• Topical agents used for dry mouth, excessive salivation, mucositis, apthous ulcers, oral candidas

• Topical agents for managing dry skin, pruritus, pressure sores, non-healing / foul smelling / bleeding wounds

• Topical anal preparations

• Topical eye preparations

CD2.5 DRUG INTERACTIONS IN PALLIATIVE MEDICINE

2.5.1

Drug Interactions

• Serotonin syndrome QT prolongation

• Drug induced movement disorders Synergistic sedation

• Metabolic interactions (Cytochrome

P450) Pharmacokinetic interactions

CD2.6 PARENTERAL ANALGESIC PREPARATIONS

2.6.1

Parenteral analgesic infusions

• Preparing analgesic infusions (non-opioids, weak opioids, strong opioids)

• Syringe driver preparations

• Syringe driver compatibility and interactions / CADD PUMP and infusion systems

• Managing a patient on syringe driver

• Drugs used in epidural and intrathecal analgesia

CD2.7 PRESCRIBING PALLIATIVE DRUGS IN SPECIAL SITUATIONS

2.7.1

Palliative drugs in special situations

• Palliative drugs in renal dysfunction

• Palliative drugs in hepatic dysfunction

• Palliative drugs in a patient with cardiovascular morbidity

• Palliative drugs in children

• Palliative drugs in elderly

• Palliative drugs in cognitive impairment

SECTION CD3: SYMPTOM CONTROL IN PALLIATIVE MEDICINE

CD3.1 PAIN

3.1.1

Introduction to Pain

• Pain definition(s)

• Pain taxonomy

• Pain classification(s)

• Acute / chronic / cancer pain – approach and differences

• Breakthrough pain

• Pain Crisis

• Emory pain estimate model

• General principles involved in managing a

patient with pain in a palliative care setting

3.1.2

Mechanism of Pain 1

• Anatomy of pain pathway

• Peripheral and spinal pain mechanisms:

o Nociception and anti – nociception

o Nociceptors

• Transduction of nociceptive pain

• Transmission of nociceptive pain

• Modulation of nociceptive pain

• Perception of nociceptive pain

3.1.3

Mechanism of Pain 2

• Nerve injury

• Peripheral and central sensitization

• Modulation in neuropathic pain

• Pathophysiological basis of hyperalgesia / allodynia

• Structural anatomy of bone in relation to

malignant bone pain

• Pathophysiological mechanisms involved in malignant bone pain

3.1.4

Assessment of Pain

• Medical evaluation of a patient with pain

• Measurement of pain and pain assessment tools – both nociceptive and neuropathic

• Role of investigations / imaging in pain patients

• Total pain –psychological / psychosocial evaluation in pain

• Evaluation of pain associated impact and disability

3.1.5

Cancer Pain Syndromes

• Cancer related acute pain situations (Diagnostic / Therapeutic interventions, anti-cancer therapy, complications)

• Cancer related chronic pain situations (Direct tumor related, anti- cancer therapy, complications, Paraneoplastic)

• Familiarity with the psychological methods in managing pain

3.1.6

Cancer Associated Nociceptive Pain

• Visceral pain syndromes

• Genitourinary pain syndromes

• Vascular pain syndromes

• Cancer related headache and facial pain

• Paraneoplastic nociceptive pain syndromes

• Lymphedema associated pain Inflammation/infection associated pain

3.1.7

Malignant Bone Pain

• Bone pain syndromes

• Pain in vertebral and long bone metastasis Mirelzs scoring system

• Imaging modalities in bone pain,

Management of bone pain (Analgesic step ladder, Bisphosphonates, Calcitonin, Radiotherapy, Radioisotopes, closed and open surgical interventions, chemo/hormonal and

targeted therapy)

3.1.8

Cancer Associated Neuropathic Pain

• Direct nerve injury (all plexopathies, painful mononeuropathy, Paraneoplastic sensory neuropathy, Malignant painful radiculopathy, Painful cranial neuralgias)

• Cancer treatment associated nerve toxicity(chemotherapy / RT associated neuropathy)

• Surgical neuropathies (Phantom limb, postmastectomy / post thoracotomy syndromes)

• Current guidelines for neuropathic pain

management

CD3.2 GASTROINTESTINAL SYMPTOMS

3.2.1

Nausea and Vomiting

• Definitions and Epidemiology

• Etiological classification of Nausea and Vomiting in Palliative Care

• Approach to a patient with Nausea and Vomiting

• Opioid induced Nausea and Vomiting

• Chemotherapy induced Nausea and Vomiting

• Radiotherapy induced Nausea and Vomiting

• Etiology specific rational management of nausea and vomiting.

3.2.2

Constipation and Diarrhea

• Comprehensive Definition / Classification

• Etiology of constipation in a palliative care setting

• Clinical approach and rectal examination

• Constipation assessment scales

• Principles of managing constipation and pharmacological approach

• Opioid induced constipation

• Managing constipation in a patient with paraplegia

• Assessment and management of diarrhea in palliative care practice

CD3.3 RESPIRATORY SYMPTOMS

3.3.1

Dyspnea

• Prevalence of dyspnea in life limiting conditions

• Pathophysiology of dyspnea

• Physiological classification of dyspnea in PC

• Assessment of dyspnea (Quality, Intensity, Impact, Distress)

• Four quadrant approach in management of dyspnea (Medical, Rehab, Palliative and End of Life Model)

• Palliative Pharmacology of Dyspnea

• Morphine in Dyspnea

• Oxygen in Dyspnea

• Non-Pharmacological management of Dyspnea

• Palliative Sedation in Intractable Dyspnea

3.3.2

Cough, Hemoptysis Respiratory Secretions, Bronchorrhea

• Cough (Pathway, causes of cough in PC setting, Non Pharmacological management, Pharmacological treatment, Management of Refractory Cough)

• Hemoptysis (Classification – Minimal, Active, Massive, Pseudo)

• Hemoptysis (Causes in PC setting, Assessment, Non Pharmacological management, Pharmacological treatment, Interventions)

• Palliation of Massive Hemoptysis

• Respiratory secretions (Prevalence, Classification, Presentation, Non Pharmacological management, Pharmacological treatment)

• Bronchorrhea (Prevalence, Clinical features, Management)

CD3.4 CNS SYMPTOMS

3.4.1

Delirium

• Understanding consciousness (Awakeness, Awareness and Alertness)

• Neurophysiology of Delirium

• Epidemiology and risk factors

• Clinical features

• Tools used in Delirium Assessment

• Bedside assessment of Delirium

• Delirium types (Hypoactive/Hyperactive/Mixed)

• Differential Diagnosis

• Management of Delirium includes correcting the underlying cause of delirium where possible (Risk assessment, Prevention, Education, Safety, Non Pharmacological treatment, Pharmacological treatment)

• Management of agitation associated with delirium including use of chemical and physical restraints

• Terminal Delirium

CD3.5 MISCELLANEOUS SYMPTOMS

3.5.1

Miscellaneous symptoms 1 (Hiccoughs, Pruritus, Sweats, Dysphagia)

• Hiccoughs (Definition, Classification, Hiccoughs pathway, Etiology in palliative care setting, Non pharmacological and pharmacological management, treatment of refractory hiccoughs)

• Pruritus –

o(Classification based on duration, Etiology, clinical presentation)

o(Pruritus pathway, chemical mediators, causes and mechanism)

o(Overall management and classification of drugs used in pruritus)

o(Pharmacological and non-pharmacological management each type)

• Sweats (Etiology, Assessment and Management)

3.5.2

Miscellaneous symptoms 2 (Fatigue and Edema)

• Etiology of fatigue in a PC setting

• Pathophysiological mechanisms of fatigue

• Clinical assessment and Tools used in Fatigue Assessment

• Non pharmacological and pharmacological management of fatigue

• Edema in PC setting

• Assessment and Management of Edema (excluding Lymphedema)

SECTION CD4: PALLIATIVE MEDICINE IN AN ONCOLOGY SETTING

CD4.1 BASICS OF ONCOLOGY

4.1.1

Cancer Epidemiology

• Cancer trends in India (Incidence and Mortality)

• Cancer etiology, risk factors and risk assessment (Tobacco, Infections, Diet, Life style, Physical and Chemical factors)

• Hereditary and Familial Cancer Syndromes

4.1.2

Cancer Biology and Natural History of Cancer

• Cancer Hallmarks (Tumor Biology, Cell cycle, Apoptosis, Cancer Stem cells, Proto- oncogenes, Tumor suppressor genes, Angiogenesis, Invasion and Metastasis)

• Cancer Genetics

4.1.3

Principles of Anticancer Therapy

• Classification, pharmacokinetics and pharmacodynamics of anticancer drugs

• Indications, dose/dose schedules, toxicity of commonly used anti- cancer drugs

• Principles, uses and pharmacology of drugs used in hormone therapy

4.1.4

Palliative Surgery

• Principles of palliative surgery in oncology setting

• Indications, morbidities of palliative surgery in individual cancer

• Common palliative surgery procedures (Colostomy, Ileostomy, Gastrostomy, Urinary diversion procedures, Tracheostomy, Stenting, ERCP/PTBD and other interventional surgical/radiological procedures)

• Orthopedic surgeries in palliative care.

4.1.5

Palliative Chemotherapy

• Principles of Cancer Chemotherapy and Palliative Chemotherapy

• Definition, Principles of Adjuvant and Neoadjuvant chemotherapy

• Indications, principles and use of metronomic chemotherapy

4.1.6

Palliative Radiotherapy

• Principles of Palliative Radiotherapy

• Role of RT in brain and malignant spinal cord compression

• Role of RT in skeletal metastasis

• Role of RT in visceral and soft tissue metastasis

• Role of RT in Hemostasis, Analgesia and management of Obstructive symptoms

CD4.2 PALLIATIVE MANAGEMENT OF COMMON CANCERS

4.2.1

Head and Neck, Brain and Thoracic cancers

• Stage‐wise management of head and neck cancers

• Palliative RT and metronomic chemotherapy in Palliative / Advanced Head and Neck Cancers

• Management of low grade and high grade brain tumors

• Role of Palliative RT in patients with GBM with low KPS / Management of brain stem gliomas and recurrent brain tumors

• Palliative management of advanced

esophageal cancers and palliative treatment of dysphagia

• Palliative management of advanced lung cancers

4.2.2

Breast and Genito-•‐ urinary cancers

• Stage-wise management of breast cancer

• Palliative management of advanced breast cancer

• Treatment algorithm of common genito-urinary cancers

• Palliative RT for advanced genito- urinarycancers

• Palliative chemotherapy for advanced genito- urinary cancers

• Palliation of obstructive Uropathy

4.2.3

GIT Cancers including Hepatobiliary

• Stage-wise management of GIT / Hepatobiliary cancers

• Palliative RT indications and schedules in advanced GI cancer

• Palliative chemotherapy for advanced GI / Hepatobiliary cancers

• Palliation of bleeding, obstructive jaundice, malignant ascites

4.2.4

Pediatric cancers, soft tissue tumors, leukemia and lymphoma

• Treatment algorithms for common pediatric cancers

• Palliative chemotherapy regimens for advanced / relapse and recurrent pediatric solid tumors, lymphomas and leukemia

• Palliative RT indications and schedules In pediatric solid tumors and lymphomas

CD4.3 CANCER COMPLICATIONS AND ONCOLOGICAL EMERGENCIES

4.3.1

Neurological Complications and Emergencies 1

• Malignant Spinal Cord Compression

• Anatomy of Spinal Cord

• Epidemiology, Types, Frequency

• Clinical presentation

• Investigations

• Conservative Management

• RT/Surgery and other interventions

• Prognostication

• Evidence base for each intervention

4.3.2

Neurological Complications and Emergencies 2

• Status Epilepticus

• Brain Metastasis

• Raised Intracranial Pressure (Cerebral Edema)

• Encephalopathy (Structural, Metabolic, Septic)

4.3.3

Hematological and Vascular Complications and Emergencies

• Malignant SVC Obstruction

• Deep venous thrombosis and Pulmonary Embolism

• Hemorrhage

• Tumor Lysis Syndrome

• Neutropenic sepsis

4.3.4

Gastrointestinal, Thoracic, Genitourinary, Bone and other Complications and Emergencies 1

• Malignant Bowel Obstruction (MBO)

• Physiologic reactions to Malignant Bowel Obstruction

• Etiological of bowel obstruction in a patient with advanced cancer

• Approach to a patient with bowel obstruction

• Proximal versus Distal Bowel obstruction

• Rationally investigating a patient with MBO

• When to consider conservative management in MBO

• Principles and steps involved in conservative management of MBO

• Pharmacology of drugs used in MBO

• Interventional techniques in MBO

• Nutrition in MBO

• Prognostication in MBO

4.3.5

Gastrointestinal, Thoracic, Genitourinary, Bone and other Complications and Emergencies 2

• Malignant Ascites

• Malignant Pleural and Pericardial Effusion

• Obstructive Uropathy

• Pathological fractures

• Airway obstruction and Stridor

• Managing Pain Crisis

• Managing Opioid Overdose

SECTION CD5: PALLIATIVE MEDICINE IN A NON-ONCOLOGY SETTING

CD5.1 END STAGE ORGAN FAILURE

5.1.1

End stage Chronic Lung Disease (CLD)

• Defining End Stage COPD

• Symptomatology of end stage COPD

• Initiation of palliative medicine in end stage COPD (Gold Standards Framework)

• 4 quadrant approach (Medical, Rehab, Palliative and EOLC)

• Dyspnea management stepladder

• Medical and Rehab models

• Palliative Model (Pharmacological / Non pharmacological)

• Opioids in Dyspnea (Mechanism/dose/evidence)

• Guidelines for initiating EOLC model in end stage COPD

• EOLC in end stage COPD

• Palliative Sedation in refractory dyspnea

5.1.2

End stage Congestive Heart Failure (CHF)

• Defining end stage cardiac failure

• Illness trajectory and various trajectory models

• Heart failure stages as relevant to palliative care

• Symptomatology of CHF

• Initiating palliative medicine in end stage CHF

• Triggers for palliative medicine referrals

• Guidelines for palliative medicine referral

• Palliative approach in end stage CHF

• EOLC in CHF

5.1.3

Chronic Kidney Disease (CKD) and End Stage Renal Disease (ESRD)

• Defining CKD and ESRD

• Burden of ESRD

• Symptom burden of ESRD

• Management of pain in patients with ESRD

• Managing non-pain symptoms in ESRD

• Non dialysis supportive care approach in CKD / ESRD

• Managing end of life in patients on dialysis

• Guidelines / recommendations for not initiation / withdrawal of

dialysis

5.1.4

End Stage Liver Disease (ESLD)

• Defining ESLD

• Symptom burden in ESLD and management of ESLD symptoms

• EOL transitions in ESLD (Child Pughzs / MELD scoring)

• Prognostication in ESLD

• Palliative and EOLC approach in ESLD

5.1.5

Palliative Neurology 1 (Symptoms and Impairment)

• Specific symptoms in advanced neurological illness (Muscular weakness, spasticity, dystonia, seizures, muscle cramps, involuntary movements, dyskinesia)

• Management of impairments secondary to advanced neurological illness (speech difficulty, dysphagia, drooling of saliva, breathing difficulty, urinary retention, bladder spasms, bowel and bladder incontinence,

sexual dysfunction, autonomic dysfunction)

5.1.6

Palliative Neurology 2 (Motor Neuron Disease)

• Classification

• Clinical Presentation

• Symptom prevalence in MND

• Etio‐pathogenesis, impact and management of dysarthria

• Management of dysphagia and Sialorrhea

• Pain in MND (Etiopathogenesis and Management)

• Dyspnea in MND (Management, Non‐ invasive ventilation, weaning of respiratory

support)

• Interdisciplinary care in MND

• End of Life Care in MND

5.1.7

Palliative Neurology 3 (Other neurological conditions needing Palliative Care)

• Palliative Care in cerebrovascular disease

• Palliative Care in demyelinating disease

• Palliative Care in Parkinsonzs disease

• Palliative Care in Muscular dystrophy

• Palliative Care in Huntingtonzs disease

• Palliative Care in traumatic and hypoxic brain injury

• Palliative care in congenital and acquired peripheral neuropathy

CD5.2 PALLIATIVE MEDICINE IN HIV/AIDS

5.2.1

Palliative Medicine in HIV AIDS 1

• HIV infections and AIDS (Epidemiology, Biology, Natural History, Pathogenesis, Phases)

• Clinical Course of AIDS

• AIDS Defining Complex

• Anti-retroviral therapy

• Infections in an immunocompromised patient

• Non infective complications of HIV/AIDS

CD5.3 PALLIATIVE MEDICINE IN DEMENTIA

5.3.1

Palliative Medicine in Dementia 1

• Epidemiology of Dementia Pathophysiology and classification Alzheimerzs Disease Frontotemporal Dementia

• Lewy Body Dementia

• Dementia in Parkinsonzs disease

• Dem due to Huntingtonzs disease

• Vascular Dementia

• HIV associated Dementia

CD 5.4 MISCELLANEOUS NON ONCOLOGICAL CONDITIONS

5.4.1

Palliative Medicine in Hematological Disorders

• Challenges and barriers in PC provision in incurable benign hematological disorders

• Palliative Care in Sickle Cell Disease (Inheritance, Clinical presentation, symptoms, needs, communication and long-term management)

• Palliative Care in Thalassemia Major (Inheritance, Clinical presentation, symptoms, needs, communication and long-term management)

• Palliative Care in other congenital hematological

disorders (both anemia and bleeding diathesis)

5.4.2

Palliative Medicine in Immunological

• Palliative Care in advanced Vasculitis Palliative Care in malignant course of Rheumatoid Arthritis

• Palliative care in advanced stages of connective tissue disorders such as Systemic Lupus Erythematosus, Progressive Systemic Sclerosis, Mixed Connective Tissue Disorder, and Sjogrenzs syndrome etc.

• Palliative Care in Progressive Pulmonary Fibrosis

5.4.3

Palliative Medicine in congenital and post traumatic disability

• Technical definitions ‐ Disability, Impairment,

activity limitation, participation restriction

• Classification of disabilities

• Interphase of Rehabilitation and PC in a patient with disability

• Palliative care for a patient with traumatic paraplegia and quadriplegia

• Palliative care for a patient with traumatic brain injuries, persistent vegetative states

• Palliative Care in congenital disabilities

5.4.4

Palliative Medicine in MDR and XDR Tuberculosis

• Criteria for diagnosing MDR and XDR TB

• Clinical presentation, symptoms, and complications

• Pharmacological management of MDR and XDR TB

• Palliative Care and End of Life Care needs in MDR XDR TB

• Geneva Declaration of Palliative Care and MDR/XDR‐TB

SECTION CD6: SUPPORTIVE CARE IN PALLIATIVE MEDICINE

CD6.1 MANAGING COMMON COMPLICATIONS IN A PALLIATIVE MEDICINE SETTING

6.1.1

Dehydration and Shock

• Approach to a patient with shock

• Hypovolemic shock diagnosis and management

• Differentiating types of shock

• Types of resuscitation fluids, its constituents and rational use

6.1.2

Fever and Sepsis

• Various definitions used in the diagnosis of sepsis

• Fever – Types of fever

• Bacteremia, Septicemia, SIRS, Sepsis, Severe Sepsis, Septic Shock, Refractory Septic Shock, MODS

• Approach to a patient with sepsis

• Complications of sepsis

• Managing a patient with sepsis (investigations + treatment)

• Rational use of broad-spectrum antibiotics

6.1.3

Anemia and Transfusion

• Anemia in advanced illness: prevalence, significance, and causes

• Approach to a patient with anemia of chronic disease and cancer

• Approach and diagnostic modalities

• Role of iron supplements

• Role of erythropoiesis stimulating agents

• Blood and component transfusion

• Assessment of fatigue and symptom benefit post blood transfusion

• Decision making on withholding transfusion

6.1.4

Anorexia-Cachexia Syndrome (ACS)

• Definition and classification of ACS Etiology of ACS in a Palliative Care setting

• Pathogenesis of primary and secondary ACS Diagnosis, Clinical Presentation, and stages Clinical assessment of ACS

• Pharmacological management of ACS Nutrition in ACS

6.1.5

Thrombotic disorders in Palliative Medicine

• Cancer associated thrombosis (pathophysiology

+ approach)

• Swollen legs in a palliative care setting (differentiating venous thromboembolism [VTE] from others)

• Recognition, confirmation and management of VTE

• Guidelines on using anti-coagulants in VTE – how long / how to monitor / when to discontinue

• Special situations – SVC thrombosis, portal venous thrombosis, cavernous venous thrombosis

CD6.2 MANAGING CONCURRENT ILLNESS IN A PALLIATIVE MEDICINE SETTING

6.2.1

Electrolyte Imbalance 1 Hyponatremia,

Hypernatremi a

• Approach to a patient with hyponatremia

• Hypovolemic hyponatremia

• Euvolemic hyponatremia

• Hypervolemic hyponatremia

• Treatment of hyponatremia (using 3% saline and pharmacotherapy of hyponatremia)

• Approach to a patient with hypernatremia

• Treatment of hypernatremia

6.2.2

Electrolyte Imbalance 2 Hypokalemia, Hyperkalemia

• Potassium homeostasis Hypokalemia – Definition, Etiology, Diagnostic approach / algorithm, Management (Pharmacological / Non-Pharmacological)

• Hyperkalemia ‐ Definition, Etiology, Diagnostic

approach / algorithm, Management (Pharmacological / Non- Pharmacological)

• Hyper and hypokalemia in a palliative care setting

6.2.3

Electrolyte Imbalance 3 Hypocalcemia, Hypercalcemia Hypomagnesaemia, Hypomagnesaemia

• Calcium and Magnesium Homeostasis –

• Definition, Etiology, Diagnostic approach / algorithm

• Management (Pharmacological / Non- Pharmacological)

• Specific clinical / laboratory diagnostic tests

• Prevention

• Relevance in a palliative care setting of:

Hypocalcemia / Hypercalcemia / Hypomagnesaemia /Hypomagnesaemia

6.2.4

Acid-Base Disorders Fluids

• General principles of acid-base balance

• Definitions and Stepwise approach

• Estimating compensatory responses to primary acid-base disorder

• Differential diagnosis

• Metabolic acidosis

• Metabolic alkalosis

• Respiratory acidosis

• Respiratory alkalosis

• Types of Intravenous fluids

• Rationale use of fluids

6.2.5

Urinary Tract Infections

• Definitions (Asymptomatic bacteruria, Uncomplicated UTI, Complicated UTI)

• Risk factors

• Symptoms and approach to a patient with complicated UTI

• Prevention and management of complicated UTI

• Catheter associated UTI (prevention and management + IDSA guidelines)

• Antimicrobials in prevention and treatment of UTI as per current guidelines

• Collecting specimens in UTI

6.2.6

Respiratory Tract Infections

• Aspiration pneumonia (risk factors, diagnosis, treatment)

• Community Acquired Pneumonia in a patient advanced illness (microbial patterns, diagnosis, treatment)

• Pseudomonas Bronchopulmonary infections

• Acute exacerbation of COPD

• Viral and fungal lung infections

• Severe and Critical COVID illness

6.2.7

Gastrointestinal and Hepatobiliary infections

• Approach to a patient with diarrhea

• Common GI infections in patients with advanced illness (bacterial/viral/parasitic) [approach + diagnosis + treatment]

• Hepato-biliary infections (Cholangitis, Hepatitis, Liver abscess)

• Peritonitis

• Bacterial infections of the oral cavity

• Oral and pharyngeal candida

6.2.8

Skin and soft tissue infections

CNS Infections

• Infected pressure sore

• Infected ulcers / wounds

• Cellulitis

• Lymphangitis Herpes

• Zoster

• Meningitis / Meningoencephalitis

CD6.3 MANAGING COMORBID ILLNESS IN A PALLIATIVE MEDICINE SETTING

6.3.1

Co morbid illness 1

• Guidelines for management of Diabetes

• Mellitus in Palliative Medicine setting

• Blood sugar control based on prognosis (years, months, days)

• Diabetes Mellitus management in End of Life phase

• Pharmacological management in Type 1 and Type 2 Diabetes Mellitus

• Insulin preparations – choices, using a sliding scale

• Managing corticosteroids induced Diabetes Mellitus

• Management of Diabetic Ketoacidosis and Non Ketotic Hyperosmolar state

• Recognition and management of Hypoglycemia

6.3.2

Co morbid illness 2

• Optimizing hypertension management and anti-hypertensive choice in palliative care setting

• Optimizing ischemic heart disease management and rationalizing use of cardiac drugs and diuretics

• Optimizing dyslipidemia and rationalizing use / stopping of lipid lowering drugs

• Optimizing use / stopping of anti-platelet drugs and anti- coagulants

• Management of other co-morbid illnesses such as (Bronchial Asthma, COPD, Hypothyroidism, Rheumatoid Arthritis etc.)

SECTION CD7: PSYCHOSOCIAL ISSUES IN PALLIATIVE MEDICINE

CD 7.1 ILLNESS EXPERIENCE AND SUFFERING

7.1.1

Illness, Suffering and Psychological issues of dying

• Human experience of illness

• Psychological response to illness

• Defining and understanding suffering

• Triangular model of suffering

• Dimensions of patient distress / suffering in a life limiting illness context

• Dimensions of family distress / suffering in a life limiting illness context

7.1.2

Defense mechanisms and Coping Strategies

• Unhealthy Defense Mechanisms – Neurotic

• Defenses (Repression, Displacement, Reaction formation, Intellectualization and Rationalization)

• Unhealthy Defense Mechanisms – Immature Defenses (Denial, Splitting, Idealization, Devaluation, Projection, Projective Identification, Acting out and Passive aggression)

• Healthy Defense Mechanisms – Mature defenses (Suppression, Altruism, Humor, Sublimation, Anticipation, Acceptance)

• Coping strategies – definition, types, explanations and

examples

7.1.3

Emotional experience of pain

• The pain experiences

• Meaning of pain in terminal illness

• Psychological impact of uncontrolled pain

• Modulatory systems involved in pain pathway that influences pain perception

• Bio-psycho‐social factors influencing pain perception

• Factors decreasing and increasing pain tolerance

7.1.4

Grief and Bereavement 1

• Definitions (Bereavement, Grief, Mourning, Anticipatory Grief, Pathological Grief and Disenfranchised Grief)

• Kubler Ross Model – 5 stages of grief

• Theoretical models of bereavement phenomenon

• Normal Grief and Clinical presentation of grief

• Factors affecting bereavement outcomes

• Typology of palliative care and bereaved families

• Recognizing those at risk of complicated grief

7.1.5

Grief and Bereavement 2

• Pathological Grief

• Clinical presentations of pathological grief

• Risk factors for complicated Grief

• Bereavement follow up and support

• Models of grief therapy

• Factors predicting outcomes of grief therapy

• Special bereavement situations

• Managing denial in anticipatory grief for

patients and family members

CD7.2 PSYCHIATRY OF PALLIATIVE MEDICINE

7.2.1

Adjustment disorder and Distress in Palliative Medicine

• Epidemiology of Adjustment disorder in PC Pathogenesis

• Diagnostic criteria

• Clinical Course and presentation Prevention and early detection Management

• Defining distress, NCCN distress

thermometer, assessment of distress and causative factors

7.2.2

Depression in Palliative Medicine

• Prevalence of depression in cancer, including advanced cancer

• Assessment – screening tools

• Diagnostic criteria

• Risk factors

• Mechanisms

• Impact on cancer

• Treatment – Psychological and Psychopharmacological

• Suicide and desire for hastened death

• Guidelines for management of depression in palliative care

7.2.3

Anxiety in Palliative Medicine

• Definition of fear and anxiety

• Screening for anxiety

• Anxiety subtypes in cancer – Generalized anxiety disorder, Panic disorder, Social anxiety disorder, Specific phobia, Anxiety due to gen med condition, Substance induced anxiety disorder, Anticipatory anxiety and nausea, Post- traumatic stress disorder

• Assessment and Differential diagnosis

• Management –

oa) Being familiar with psychological interventions for anxiety as Cognitive behavior therapy, Behavioral interventions,

Others

ob) Pharmacological management of anxiety

7.2.4

Dealing with personality traits/disorders in Palliative Medicine practice

• Identification of personality trait / disorder, personality characteristics, meaning of illness, Transference / Counter transference response, management of personality and illness

• Describing the above in the following personality trait / disorder (Dependent, Obsessive compulsive disorder, Histrionic, Borderline, Narcissistic, Paranoid, Anti-social

and Schizoid)

7.2.5

Dealing with patients with chronic mental illness in Palliative Medicine practice.

• Affective disorders

• Psychotic disorders

• Alcohol dependency

• Post traumatic disorders

• Intellectual disabilities

• Approach to a patient with chronic mental illness in PC practice

• Approach to a patient with dementia and specially at the end of life care of a patient with dementia

• Risk management of patients undergoing palliative treatment – Managing risk of

completed suicide, Risk of self harm,

neglect, nutritional risk, risk of wandering away and risk of harming others in a multidisciplinary team

7.2.6

Psychological issues in a patient with brain neoplasm

• Neuropsychiatric changes in a patient with brain tumor and Leptomeningeal disease (Seizures, Loss of motor functions, Headache, alteration mental status, cognitive dysfunction, personality and behavioral changes, anxiety and mood changes and Hallucinations)

• Psychiatric symptoms and cerebral tumor location

• Treatment related psychiatric side effects (corticosteroid euphoria, corticosteroid bipolarity, steroid dementia, steroid

dependence, body image issues)

7.2.7

Dying Mind

• Twilight states

• Lightening before death

• Near death experiences

• Last words

• Terminal restlessness

CD7.3 DISTRESS, SPIRITUAL AND EXISTENTIAL ISSUES

7.3.1

Spiritual and Existential issues in Palliative Medicine

• Defining Spirituality, Concepts of Religion and Spirituality

• Understanding spiritual distress

• Spirituality Assessment and tools used in measuring spiritual distress

• Providing spiritual care (who and how)

• Components of spiritual care (Humane Presence, Listening and Acknowledging, Helping complete unfinished business, Meaningful Communication, Sustaining Personhood and Reconnecting with the community)

• Existential distress and managing Existential

issues

CD7.4 PSYCHOSOCIAL SUPPORT

7.4.1

Care giver support

• Types of caregivers

• Caregiver burden

• Tools to measure caregiver burden

• Psychosocial problems of caregivers

• Interventions to deal with family caregiver burden

• Support groups in Palliative Medicine

7.4.2

Self-care

• Burnout (Definition, risk factors, markers)

• Compassion fatigue

• Burnout in PC practice and factors influencing burnout unique to PC

• Concept of self-care

• Self-assessment and self-care plans

• Self-care Protective Practices, Protective Skills and Protective

Arrangements

SECTION CD8: PEDIATRIC AND GERIATRIC PALLIATIVE MEDICINE, END OF LIFE CARE

CD8.1 PEDIATRIC PALLIATIVE MEDICINE

8.1.1

Introduction to Pediatric Palliative Care

• Children needing palliative care (from WHO Global Atlas of Palliative Care 2014)

• Edmarc experience

• Pediatric Palliative Care in India + Level of integration

• WHO definition of pediatric palliative care

• ACT/RCPCH pediatric palliative care (PPC) trajectory of illness (Group I to Group IV)

• Triaging in pediatric palliative care (4 triage groups)

• Differences between adult and pediatric palliative care

• Square of care in PPC

• Barriers involved in PPC provision

• Broad format of pediatric palliative care provision (Physical, Psycho-social, Spiritual, Advanced Care planning and Practical)

• Models of care in childrenzs palliative

care (Foot prints, CHI- PACC, IPPC)

8.1.2

Pediatric Pain 1

• Etiological classification of pain in PPC

• Algorithm for evaluation of pain in the pediatric population

• Pain history taking in PPC

• Pain expression in children

• Detailed description of various age and situation specific pain assessment scales in children

• Guidelines for administering and interpreting pain assessment tools in children

• Assessment of impact of pain in children

8.1.3

Pediatric Pain 2

• Principles of pharmacological treatment of pain in children

• WHO two step ladder for pain management in children

• Using non‐opioids for pain in children (Drugs, formulations, and dosing)

• Using opioids for pain in children (Drugs, formulations, and dosing)

• Adjuvant analgesics for managing pain in children

• Non pharmacological management of pain in children

8.1.4

Pediatric non pain symptoms

• Pediatric Delirium (Pathophysiology, etiology, clinical presentation, pediatric delirium assessment, using pCAM questionnaire in children, pediatric delirium assessment scales, pharmacological and non-pharmacological management of pediatric delirium)

• Dyspnea and intractable cough in children (etiology, assessment and management)

• Assessment and management of nausea and vomiting in children

• Assessment and management of constipation in children

8.1.5

Pediatric Palliative Care in Cancer

• Approach to a child with advanced cancer

• Supportive Care issues in Pediatric Oncology

• Palliative care in specific pediatric solid tumors (Retinoblastoma, PNET, Neuroblastoma, bone tumors, Hepatoblastoma, Wilm‟s tumor etc.)

• Palliative care in specific pediatric Hemato‐ Lymphoid malignancies

8.1.6

Pediatric Palliative Care in Non-Cancer conditions

• PPC in chronic pediatric neurodegenerative conditions

• PPC in Hemolytic Anemia (Thalassemia and Sickle Cell Disease)

• PPC in Cystic Fibrosis

• PPC in Congenital Heart Diseases

• PPC in Inborn errors of metabolism and chromosomal abnormalities

8.1.7

Psychosocial, communication and ethical issues specific to Pediatric Palliative Care

• Children‟s views of death

• Communication with children in PPC

• Impact of serious life limiting illness on family ‐ parents and siblings

• Psychological adaptation of the dying child

• Guidelines for working with the dying child

• Decision-making and ethical issues in pediatric palliative care

• Factors affecting bereavement and

bereavement support and interventions

8.1.8

Adolescent Palliative Medicine

• Classification of adolescents based on physical and cognitive states

• Life limiting conditions affecting adolescents and young adults needing palliative medicine.

• Specific palliative care needs in early / mid / late adolescents

• Psycho‐social issues specific to

Adolescent Palliative Medicine

• Manifestations of grief in adolescents age group

CD8.2 GERIATRIC PALLIATIVE MEDICINE

8.2.1

Aging

• Socio-demographics of Aging with emphasis on developing countries

• Theories and Biology of ageing

• Physiology of aging

• Implications of aging in health care and palliative care

8.2.2

Frailty

• Definition

• Prevalence

• Pathophysiology and clinical features

• Tools to measure frailty

• Risk factors for falls Comprehensive assessment and interventions

8.2.3

Management of older individuals needing Palliative Care

• Broad dimensions of problems in elderly population

• Geriatric assessment and geriatric assessment tools

• Common medical problems in elderly and their management

• Common psychological / psychiatricmorbidity in elderly

• Practical, Social and Emotional issues

• Decision making, goals of care and end of life care in older individuals receiving PC

CD8.3 END OF LIFE CARE

8.3.1

End of Life Care 1

• Estimating EOLC needs in the community.

• Gaps in EOLC needs in India across various clinical setting

• Prognostication

• Principles of Good Death

• Components of Good Death

• Steps involved in providing Good End of Life Care

oRecognizing the dying process oEnd of Life Decision Making oInitiation of EOLC

oProcess of EOLC oAfter death Care

• Recognizing the dying process

• EOLC decision making (Timing, Decision

Makers, Shared Decision Making)

8.3.2

End of Life Care 2

• Ethical aspects specific to EOLC (Autonomy and Beneficence, Autonomy and Non maleficence, non- abandonment and Non Maleficence, Disclosure and beneficence, Fair allocation of societal resources)

• Special ethical situations (Futility of treatment and Euthanasia)

• Legal aspects of EOL as applicable to India

8.3.3

End of Life Care 3

• Principles of EOLC symptom management

• 6 step EOLC approach (Identify – Assess – Plan – Provide – Reassess – Reflect)

• Respiratory secretions in EOLC

• Nursing Interventions in EOLC

• Palliative Sedation

• Silver hour

• End of Life Care process and pathways

8.3.4

End of Life Care 4

• Principles of after death care.

• 4 step approach in verification and certification of death (verification – certification – reporting – registration)

• International guidelines for verification of death. Verification of death in primary care, hospital, ICU and comatose patients

• Registration of Births and Death Act 1969

• Writing a death certificate

• Death Certificate form

• When not to issue death certificate

• 6 recommendations of IAPC consensus position statement on EOLC policy

• IAPC + ISSCM joint society 12 step guidelines on EOLC

SECTION CD9: SPECIAL TOPICS IN PALLIATIVE MEDICINE

CD9.1 SPECIAL TOPICS IN PALLIATIVE MEDICINE

9.1.1

Sleep in Palliative Medicine

• Sleep physiology

• Sleep theories

• Sleep disturbances in advanced cancer

• Tools to measure sleep related parameters

• Management of sleep disorders

9.1.2

Body image and Sexuality in Palliative Medicine

• Body image and sexuality in different illnesses

• Sexuality in cancer

• Psychosocial predictors of sexual functioning after cancer

• Sexual history taking

• PLISSIT model

• Interventions to improve sexual functioning

9.1.3

Ethical Issues in Palliative Medicine 1 (Basics)

• Principles and theories

• Cardinal principles of Medical Ethics and its application (Autonomy, Beneficence, Non-Maleficence, Justice)

• Decision making capacity / Surrogate Decision making

• Confidentiality

• Informed Consent

9.1.4

Ethical Issues in Palliative Medicine 2 (Special situations)

• Limitation of disease modifying treatment

• Withholding and withdrawing of life sustaining treatment

• Nutrition and Hydration

• Ethical situations in end-of-life decision making and end of life care

• Conflict and Collusions

• Palliative care research

9.1.6

Communication skills Training 1 (Basics of Communication and Breaking bad News)

• Basics of communication

• Patient centered communication (Goals of patient centered communication, Active Listening, Pre-requisites for good communications, Outcomes of good communication)

• Verbal and Non-verbal behaviors

• Basics of bad news and truth telling

• SPIKES Protocol/CLASS Approach in Breaking Bad News (BBN)

• Unhelpful statements/Avoiding Pitfalls/Barriers and Reactions to BBN

• (All these discussions should be undertaken along with Role Play)

9.1.7

Communication Skills training 2

(Dealing with

Common

• Informed consent

• Decision making

• Uncertainty

• Denial

Communication Issues)

• Cessation of disease modifying care

• Transition of care

• Discussing prognosis and life expectancy

• Discussing future symptoms

• Discussing goals of care

• Discussing life sustaining treatment

• End of life care communication

(All these discussions should be undertaken along with Role Play)

9.1.8

Communication Skills training 3

(Advanced Medical Communication Situations)

· Cessation of disease modifying care

· Transition of care

· Discussing prognosis and life expectancy

· Discussing future symptoms

· Discussing goals of care

· Discussing life sustaining treatment

· End of life care communication

(All these discussions should be undertaken along with Role Play)

CD9.2 PALLIATIVE MEDICINE IN SPECIAL SITUATIONS

9.2.1

Palliative Medicine in Bone Marrow/Stem Cell Transplantation

• Physical symptoms specific to stem cell transplantation

• Psychosocial issues specific to stem cell transplantation

• Management of physical symptoms – Rational Pharmacology specific to SCT

• Management of psychosocial issues – Rational Psychopharmacology specific to SCT

• Communication issues in SCT

• Transitions of care and End of Life in SCT

9.2.2

Palliative Medicine in Intensive Care

• Situations in intensive care setting where palliative care is appropriate

• Approach, decision making and transitions of care in ICU

• Communication with families regarding palliative care in the ICU setting

• Ethical and legal considerations of limiting life- sustaining treatment in ICU

• Guidelines for limiting life-sustaining treatment

and providing palliative care / end of life care in ICU

9.2.3

Medico-legal aspects of palliative care

• Having an understanding of „mental capacity to consent to treatment‟

• Having an understanding of „mental capacity to participate in research in palliative care‟

• Testamentary capacity – boundaries and problems

• Legal aspects of elder abuse

• Euthanasia: International standing, present Indian Law

• Physician Assisted suicide: International standing, present Indian Law

• Legal aspects and Laws related to prescribing medication including opiates

• Parental responsibility of children: What to do when two parents disagree for a child needing

palliative care?

9.2.4

Understanding management principles of running a palliative medicine service

• Have an understanding of management principles in Running and setting up a new palliative care service

• Quality control

• Team working

• Clinical governance and audit

• Managing complaints

• Handling underperforming juniors

• Brief introduction to accreditation processes (NABH, ESMO etc.)

9.2.5

Have a good understanding about the ethical aspect of palliative medicine

• Principles of medical ethics

• Framework for ethics-based decision making

• Ethical considerations in Medical Futility, limiting life-sustaining treatment and euthanasia

• Best interest principles in ethics-based decision making

• Ethical considerations in paediatric palliative

care

9.2.6

Perinatal Palliative Medicine

• Definition and scope of perinatal palliative medicine

• Conditions suitable for perinatal palliative medicine

• Pain assessment in fetuses and newborn

• Stages of planning in perinatal palliative medicine (Antenatal planning, pre-birth care, intrapartum and postpartum care)

• End of life care decisions in babies with adverse

prognosis

CD9.3 PROCEDURES, INTERVENTIONAL TECHNIQUES IN PALLIATIVE

MEDICINE

9.3.1

Procedures and Interventional techniques in Palliative Medicine 1

• Parenteral opioid infusions, setting up a syringe driver, syringe driver compatibility, dosing and titration, monitoring, anticipating complications and mitigation mechanisms

• Epidural and Intrathecal Analgesia, technical aspects of procedure, dosing and titration, managing a patient with Epidural and Intrathecal catheter, Early and Late complications of intrathecal and epidural analgesia

• Site specific neurolytic procedures

9.3.2

Procedures and Interventional techniques in Palliative Medicine 2

• Oxygen, Oxygen delivery systems, cannula masks and venture, noninvasive ventilation, Tracheostomy

• Abdominal paracentesis, pleurocentesis, pericadiocentesis, Intercostal drains

• Nasogastric / Nasojejunal tubes, Percutaneous gastrostomy, Feeding Jejunostomy, peritoneal catheter for ascetic tap, percutaneous biliary drainage and other stenting procedures

• Urinary catheters including suprapubic,

Percutaneous nephrostomy, DJ stenting

CD 9.4 COMPLEMENTARY AND ALTERNATIVE MEDICINE IN PALLIATIVE

MEDICINE

9.4.1

Complementary and Alternative Medicine (CAM) 1

• NCCAM Classification (Alternative Medical System, Mind Body Medicine, Biologic Based Therapy, Energy Based Therapy, Electrical / Mechanical Stimulation)

• CAM‐PC Interphase

• CAM interventions (Acupuncture, Acupressure, Aromatherapy, Hypnosis, Meditation / Relaxation, Music Therapy, Reflexology, Reiki, Yoga)

• Alternative Medical Systems (Ayurveda,

Homeopathy and Herbal Medicine)

9.4.2

Complementary and Alternative Medicine (CAM) 2

• CAM in Pain Management

• CAM in Management of Nausea

• CAM in Management of Dyspnea

• CAM in Management of Fatigue, Anorexia Cachexia Syndrome

• CAM in Anxiety and Depression

• Evidence based clinical practice guidelinesfor management for Integrative Oncology

• CAM and Botanical preparations

SECTION CD10: NURSING AND REHABILITATIVE CARE IN PALLIATIVE MEDICINE

CD10.1 NURSING CARE IN PALLIATIVE MEDICINE

10.1.1

Care of Stomas 1

(Colostomy and Ileostomy)

• Classification and detailed description of

each types (Temporary Colostomy, Decompressive Colostomy, Diverting

Colostomy, Permanent Colostomy, Ileostomy)

• Management of a patient with colostomy and Ileostomy (Pre- op education, facilitating adaptation, pouching, odor and gas management, Activities in a patient with colostomy‐ADLs, sexual activity, travel, sports etc.)

• Dietary management of a patient with colostomy and ileostomy Ileostomy care and special issues in Ileostomy care

• Colostomy irrigation

• Complications of colostomy and ileostomy and management of complications

• Patient education and information

10.1.2

Care of Stomas 2 (Tracheostomy,

Urostomy, Gastrostomy)

• Timing and indications for tracheostomy

• Techniques and contraindications for

tracheostomy

• Immediate post-op care in tracheostomy

• Technique of changing the tracheostomy tube

– things to look for

• Decannulation

• Complications in a patient with tracheostomy

• Nursing care of a patient with tracheostomy

• Patient education and information

• Urinary diversion – overview and indications

• Ileal conduit and continent cutaneous diversions

• Complications of urinary diversion procedures

• Nursing care of a patient with ileal conduit

• Care of a patient with percutaneous

nephrostomy

• Care of Gastrostomy and Jejunostomy

• Care of a patient with Nasogastric and Nasojejunal tube

10.1.3

Lymphedema

• Anatomy and Physiology of Lymphatic system

• Pathophysiology and classification

• Cancer associated Lymphedema

• Clinical features and staging of Lymphedema

• Approach to a patient with Lymphedema (History and Examination)

• Clinical and anthropometric measurements and relevant investigations

• Differential diagnosis and complications

• Prevention of Lymphedema

• Treatment of Lymphedema

• Complete Decongestive Therapy (CDT) in Treatment Phase and Maintenance Phase Components of CDT (Manual lymphatic draining, compression bandaging and garments, Exercise and Elevation, Skin care) Devices used in management of Lymphedema

• Pharmacological treatment of lymphedema

10.1.4

Malignant Wounds, Chronic Malignant / Non Malignant Fistulas and Sinuses

• Tumor Necrosis (Definition, Pathophysiology, Assessment and Management)

• Comprehensive assessment of a malignant wound

• Management of a malignant wound (Exudate, Odor, Bleeding, Infection, Pain)

• Myiasis (Maggots)

• Topical dressings and drugs used in management of malignant wound

• Fistulas (Definition, Pathophysiology, Assessment and Management)

• Sinuses (Assessment and Management)

• Role of radiotherapy for malignant ulcers

10.1.5

Pressure Ulcers

• Pathogenesis and risk factors for pressure ulcers

• Risk prediction scales (Norton and Braden)

• Clinical features

• NPUAP staging

• Stage wise management of pressure ulcers

• Local measures and dressing used

• Role of surgical interventions in pressure ulcers

• Other treatment techniques (negative pressure therapy, hyperbaric oxygen, ultrasound, electrical stimulation)

• Prevention of pressure ulcers (pressure redistribution techniques, positioning techniques, skin care, other supportive techniques ‐ mobility/nutrition etc.)

• Infectious and non‐infectious complications of

pressure ulcers

• Patient education and information

10.1.6

Bladder and Catheter Care

• Catheter associated UTI (Risks, mechanisms, Diagnostic criteria, Clinical features, common organisms, complications)

• Management of catheter associated UTI (Stepwise protocol, Antibiotic regimes, Supportive treatment)

• Common types of catheters and bags (Catheter makes, balloon types, balloon sizes, catheter sizes and diameters, bags and insertion gel)

• Technique of insertion and removal

• Types of catheterization (short / intermediate and long term)

• Catheterization methods (Intermittent, indwelling, suprapubic, condom)

• Problems associated with long term catheter

• Principles of care of urinary catheter

• Patient education and information

10.1.7

Oral Care 1

• Clinical Assessment of Oral Cavity – 8

• Component assessment (Voice, Swallowing, Lips, Tongue, Saliva, Gums, Teeth / Dentures, Mucus Membrane)

• Five stage model of Oral Mucositis (OM)

• Causes and etiopathogenesis of OM

• WHO Scale / NCI‐CTC-AE Grade of OM

• Clinical Stages of OM

• Management of OM (Stepped Protocol –Basic Oral Care, Bland Rinses, Topical Analgesics / Anesthetics / Mucosal Coating agents, Systemic Analgesics)

• Combination Mouth Washes (Miracle Mouth Wash 1 and 2 / Magic Mouth Wash etc.)

• Prevention of OM

10.1.8

Oral Care 2

• Halitosis (3 stage scale / Organoleptic Scoring Scale, Assessment and Management)

• Xerostomia (Definition, Pathophysiology, Etiology, Xerostomia index, Sialagogues, Non Pharmacological Management)

• Sialorrhea (Assessment and Management)

• Dysgeusia (Assessment and Management)

• Oral Candida (Causative organisms, Clinical types, Clinical Presentation, Treatment and Prevention)

• Bacterial and viral infections of oral cavity

10.1.9

Incontinence Care

• Bladder physiology including nerve supply

• Urinary Incontinence (Definition, Pathophysiology and Epidemiology)

• Clinical types of Urinary Incontinence with detailed description of each type (Urge, Stress, Mixed, Overflow, Continuous)

• Algorithm of assessment and management of Urinary Incontinence (including etiology for each type)

• Pharmacological management of Urinary Incontinence

• Overall management of each type of urinary incontinence

• Fecal incontinence (Epidemiology,

pathophysiology, clinical presentation)

• Algorithm for evaluation of a patient with fecal incontinence

• Management of fecal incontinence and general bowel management

• Management of a patient with Vesico-

Vaginal fistula and Recto-Vaginal fistula

10.1.10

Nursing Care in Bedridden patients and patients with altered mental status

• Common nursing issues in a bedridden patient

• Common nursing issues in a unconscious patient

• Assessment and management of nutritional needs

• Airway protection and prevention of aspiration

• Skin care

• Positioning

• Bowel management

• Mucosal care

• Prevention of delirium and depression

• Preventing infections

• Safety and fall prevention

10.1.11

Nursing Care in End of Life

• Assessment of end of life care symptoms

• Assessment of nonphysical needs in end of life

• Anticipatory prescription and prompt response to symptoms

• Non pharmacological management of respiratory secretions, pain, restlessness, dyspnea

• CAM therapies in end of life After death care

CD10.2 REHABILITATIVE CARE IN PALLIATIVE MEDICINE

10.2.1

Quality of Life, Performance Status and Mobility

• Definition and structure of quality of life

• Multi-dimensional assessment of QOL

• Health related QOL in PC

• Karnofsky Performance Scale (Uses, Structure, Validity)

• Eastern Cooperative Oncology Group (ECOG)

• Scale (Uses, Structure, Validity)

• Barthel index

10.2.2

Medical Rehabilitation of a Palliative Care

Patient 1

• Rehabilitation in Palliative Care

• Rehabilitation team

• Needs assessment, integration, goal setting and

delivery

• Pulmonary Rehabilitation

• Speech and language rehabilitation

• Swallowing rehabilitation

10.2.3

Medical Rehabilitation of a Palliative Care Patient 2

• Rehabilitation of palliative care patients with motor deficits

• Rehabilitation of palliative care patients with sensory deficits

• Rehabilitation of palliative care patients with cranial nerve deficits

• Rehabilitation of palliative care patients with cognitive dysfunction

• Rehabilitation of palliative care patients with de conditioning

10.2.4

Nutrition and Hydration in Palliative Medicine

• Nutrition and cancer / chronic illness

• Nutritional and Hydration assessment

• Principles of nutrition therapy (Indications and routes)

• Enteral and parenteral nutrition in terminally ill patient

• Hydration in a terminally ill patient

Career Options

After completing a DNB in Palliative Medicine, candidates will get employment
opportunities in Government as well as in the Private sector.

In the Government sector, candidates have various options to
choose from, including Registrar, Senior Resident, Demonstrator, Tutor, etc.

While
in the Private sector the options include Resident Doctor, Consultant, Visiting
Consultant (Palliative Medicine), Junior Consultant, Senior
Consultant (Palliative Medicine), Consultant Palliative Medicine Specialist, etc.

Courses After DNB in Palliative Medicine Course

DNB in Palliative
Medicine is a specialization course that can be pursued
after finishing MBBS. After pursuing a specialization in DNB (Palliative Medicine), a candidate could also pursue super
specialization courses recognized by NMC, where DNB (Palliative Medicine) is a feeder qualification.

Frequently
Asked Questions (FAQs) – DNB in Palliative Medicine
Course

Question: What is a DNB in Palliative Medicine?

Answer: DNB Palliative Medicine or Diplomate of National Board in Palliative
Medicine also known as DNB in Palliative Medicine is a Postgraduate level course for doctors in
India that is done by them after completion of their MBBS.

Question: Is DNB in Palliative Medicine
equivalent to MD in Palliative Medicine?

Answer: DNB in Palliative Medicine is
equivalent to MD in Palliative Medicine, the list of recognized qualifications awarded by NBE in various broad and
super specialties as approved by the Government of India are included in the
first schedule of the Indian Medical Council Act, 1956.

Question: What is the
duration of a DNB in Palliative Medicine?

Answer: DNB in Palliative Medicine is a postgraduate programme of three years.

Question: What is the eligibility
of a DNB in Palliative Medicine?

Answer: Candidates must be in possession of an
undergraduate MBBS degree from any college/university recognized by the Medical
Council of India (now NMC).

Question: What is the scope of a DNB in Palliative Medicine?

Answer: DNB
in Palliative Medicine offers candidates various employment opportunities
and career prospects.

Question: What is the average salary for a DNB in Palliative Medicine postgraduate
candidate?

Answer: The DNB in Palliative Medicine candidate’s average salary is between Rs. 3 Lakh to Rs. 8 Lakh per annum depending on the experience.

Question: Are DNB Palliative Medicine and MD Palliative
Medicine equivalent for pursuing teaching jobs?

Answer: The Diplomate of National Board in
broad-speciality qualifications and super speciality qualifications when
granted in a medical institution with attached hospital or in a hospital with
the strength of five hundred or more beds, by the National Board of
Examinations, shall be equivalent in all respects to the corresponding
postgraduate qualification and the super-speciality qualification granted under
the Act, but in all other cases, senior residency in a medical college for an
additional period of one year shall be required for such qualification to be
equivalent for the purposes of teaching also.

Leave a Reply

Your email address will not be published. Required fields are marked *