Entrustable Professional Activities

EPA 10: Manage patients with untreatable life-limiting cardiac conditions

EPA 10

Life-limiting cardiac conditions

Manage the care of patients with untreatable life-limiting cardiac conditions

This activity requires the ability to:

  • assess and manage patients with chronic and acute life-limiting cardiac conditions
  • support patients to plan for their advance care and document their own wishes
  • provide care that aligns with patients' goals and values
  • monitor and adjust treatments to manage patients' symptoms and improve and/or maintain their comfort and quality of life
  • recognise when curative treatments have been exhausted, and review and rationalise medications to reduce polypharmacy (if appropriate)
  • initiate palliative care processes
  • collaborate with other healthcare providers

Professional practice framework domain

Medical expertise

confident
Ready to perform without supervision

Expected behaviours of a trainee who can routinely perform this activity without needing supervision

The trainee will:

  • assess patients' physical and psychological symptoms
  • identify impacts on patients' independence and functioning
  • provide appropriate and individualised holistic symptom management that aligns with patients' wishes
  • recognise and assess functional decline (e.g. resulting from CHF or AMI)
  • prescribe and review medications to manage symptoms and improve quality of life
  • modify treatments in response to impacts of comorbidities
  • assess patients' adherence to treatment recommendations
  • review the goals of care and treatment plans with patients, their family or carers if significant changes in patients' condition or circumstances occur
  • manage comorbidities in consultation with other health professionals involved in patients' care
  • avoid unnecessary investigations or treatment
  • recognise and manage the terminal phase in a timely way
  • advise on device management for patients in the dying phase, including deactivation of implanted mechanical supports

direction
Requires some supervision

Possible behaviours of a trainee who needs some supervision to perform this activity

The trainee may:

  • provide timely assessment and document patients' care plans
  • manage physical symptoms in alignment with patients' wishes
  • take steps to alleviate patients' symptoms and distress

Communication

confident
Ready to perform without supervision

Expected behaviours of a trainee who can routinely perform this activity without needing supervision

The trainee will:

  • establish supportive relationships with patients, their families or carers based on understanding, trust, empathy, and confidentiality
  • facilitate discussions with patients, families and carers regarding goals of care
  • communicate estimated prognoses appropriately, if requested, including the uncertainties around such estimates
  • support patients, families and carers to make informed decisions about withdrawing and/or withholding treatment
  • recognise carer stress and identify and refer to appropriate resources

direction
Requires some supervision

Possible behaviours of a trainee who needs some supervision to perform this activity

The trainee may:

  • discuss with patients, family or carers the goals of care and treatment, and document this in patients' clinical records
  • ensure consistent messages are given to patients, families or carers about treatment options, their likelihood of success, risks, and prognoses
  • provide an honest and clear clinical assessment summary of the situation using plain language, avoiding medical jargon

Quality and safety

confident
Ready to perform without supervision

Expected behaviours of a trainee who can routinely perform this activity without needing supervision

The trainee will:

  • review and rationalise medications
  • participate in multidisciplinary mortality and morbidity reviews, and provide feedback to colleagues
  • seek feedback about the quality of care from multidisciplinary team members, patients, and families or carers

direction
Requires some supervision

Possible behaviours of a trainee who needs some supervision to perform this activity

The trainee may:

  • communicate the content of discussions about prognoses and advance care planning to multidisciplinary teams
  • ensure that actual care is aligned with patients' documented wishes

Teaching and learning

confident
Ready to perform without supervision

Expected behaviours of a trainee who can routinely perform this activity without needing supervision

The trainee will:

  • provide supervision, support and teaching to develop the skills of junior colleagues
  • reflect on personal practice to guide continuing professional development

direction
Requires some supervision

Possible behaviours of a trainee who needs some supervision to perform this activity

The trainee may:

  • participate in education on disease-specific symptom assessment and evidence-based symptom management
  • encourage junior colleagues to participate in multidisciplinary case reviews, mortality and morbidity reviews, and adverse event reviews

Research

confident
Ready to perform without supervision

Expected behaviours of a trainee who can routinely perform this activity without needing supervision

The trainee will:

  • use systematic reviews or personal reviews and appraisal of available literature as evidence for appropriate management
  • support clinical trials to build the end-of-life care evidence base

direction
Requires some supervision

Possible behaviours of a trainee who needs some supervision to perform this activity

The trainee may:

  • recognise that the evidence may be insufficient to resolve uncertainty and make definitive decisions

Cultural safety

confident
Ready to perform without supervision

Expected behaviours of a trainee who can routinely perform this activity without needing supervision

The trainee will:

  • practise culturally responsible medicine based on understanding the personal, historical, and cultural influences on patients, families or carers
  • support patients, families or carers to include cultural or religious practices in their care

direction
Requires some supervision

Possible behaviours of a trainee who needs some supervision to perform this activity

The trainee may:

  • respond to and respect individual preferences and needs of patients, regardless of culture and religious beliefs
  • support patients and families or carers with communication difficulties associated with cultural and linguistic diversity

Ethics and professional behaviour

confident
Ready to perform without supervision

Expected behaviours of a trainee who can routinely perform this activity without needing supervision

The trainee will:

  • enhance quality of life for patients in the dying phase by avoiding unnecessary investigations or treatments
  • recognise the complexity of ethical issues related to human life and death
  • maintain professional boundaries in managing end of life

direction
Requires some supervision

Possible behaviours of a trainee who needs some supervision to perform this activity

The trainee may:

  • ensure that information on advance care plans, treatment plans, goals of care and patients' treatment preferences is available to all involved in patients' care

Judgement and decision making

confident
Ready to perform without supervision

Expected behaviours of a trainee who can routinely perform this activity without needing supervision

The trainee will:

  • maximise patients' autonomy and their best interests when negotiating treatment decisions
  • recognise appropriate timing for deactivation of implanted devices
  • liaise with other relevant services (e.g. palliative care services) and provide referral as necessary

direction
Requires some supervision

Possible behaviours of a trainee who needs some supervision to perform this activity

The trainee may:

  • define and document patients' and family or carers' goals and agreed outcomes

Leadership, management, and teamwork

confident
Ready to perform without supervision

Expected behaviours of a trainee who can routinely perform this activity without needing supervision

The trainee will:

  • define the roles and responsibilities of team members involved in patients' care
  • ensure care plans are communicated to all teams involved in patients' care to avoid ambiguity in treatment goals and futile and/or unwanted treatments
  • achieve agreement between multidisciplinary teams about patients' treatment options
  • coordinate care and support to be provided in patients' preferred place of care

direction
Requires some supervision

Possible behaviours of a trainee who needs some supervision to perform this activity

The trainee may:

  • document multidisciplinary care plans

Health policy, systems, and advocacy

confident
Ready to perform without supervision

Expected behaviours of a trainee who can routinely perform this activity without needing supervision

The trainee will:

  • participate in developing frameworks for organisational advance care planning
  • advocate for the needs of individual patients, social groups, and cultures within the community who have specific palliative care needs or inequitable access to palliative care services
  • apply local institutional policies relevant to the process of withdrawal of advanced life-sustaining therapies

direction
Requires some supervision

Possible behaviours of a trainee who needs some supervision to perform this activity

The trainee may:

  • allocate scarce health care resources effectively