Entrustable Professional Activities

EPA 12: End-of-life care

EPA 12

End-of-life care

Manage the care of patients at the end of their lives

This activity requires the ability to:

  • recognise the dying phase
  • support patients to plan for their advance care and document their own wishes
  • manage end-of-life care plans

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:

  • accurately assess patients’ symptoms, including physical, psychological, and spiritual aspects
  • estimate prognosis and communicate this appropriately, if requested, including the uncertainties around such estimates
  • develop and clearly document individualised end-of-life care plans, including patients’ preferences for treatment options, resuscitation plans, preferred place of care, and preferred place of death
  • provide holistic symptom management focusing on psychological and physical distress, according to patients’ wishes
  • avoid unnecessary investigations or treatment, ensuring physical and psychosocial support
  • review the goals of care and treatment plans with patients, family or carers if significant changes in patients’ condition or circumstances occur
  • recognise and manage the terminal phase in a timely way

direction
Requires some supervision

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

The trainee may:

  • demonstrate an understanding of the principles of care for patients at the end of their lives
  • provide timely assessment and document patients’ care plans
  • manage physical symptoms in alignment with patients’ wishes
  • take steps to alleviate patients’ symptoms and distress
  • correctly identify patients approaching the end of life, and provide symptomatic treatment
  • adequately manage patients in their terminal phase

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 and their family or carers based on understanding, trust, empathy, and confidentiality
  • explore thoughtfully patients’ concerns across physical, cultural, and psychological domains
  • identify opportunities to discuss end-of-life care, aligning it with patients’ values and preferences
  • identify proxy decision makers patients wish to be involved in discussions about their end-of-life care
  • identify and document lists of close family members or carers and develop support plans for them
  • provide bereaved families or carers with written information about access to bereavement support
  • communicate effectively and in a timely manner with other health professionals involved in patients’ care
  • discuss reportable death protocols, including the medicolegal implications, with families and/or carers

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 prognosis
  • provide an honest and clear clinical assessment summary of the situation, using plain language and avoiding medical jargon
  • discuss with family or carers appropriate support and bereavement care

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:

  • conduct medication chart safety audits, multidisciplinary mortality and morbidity reviews, and provide feedback to colleagues
  • develop monitoring and evaluation strategies to capture feedback about the quality of care from multidisciplinary team members, patients, and families or carers
  • review all deaths to determine the safety and quality of patients’ end-of-life care and how it could be improved
  • review technological systems and processes that support safe and high-quality end-of-life care
  • submit reportable death documentation as per local protocols

direction
Requires some supervision

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

The trainee may:

  • collect and review data on the safety and effectiveness of end-of-life care delivery
  • communicate the content of discussions about prognosis and advance care planning to multidisciplinary teams
  • ensure that actual care is aligned with documented patient 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 on end-of-life care
  • recognise feelings of moral distress and burnout in themselves and colleagues
  • reflect on personal practice and use this process to guide continuing professional development
  • ensure all members of multidisciplinary teams receive education on their roles and responsibilities for managing end-of-life care
  • promote education covering:
    • ethical and medicolegal issues
    • relevant legislation in the state, territory, or region
    • competencies for providing culturally responsive end-of-life care to Aboriginal and Torres Strait Islander and Māori peoples, and to people from other cultural backgrounds

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
  • participate in upskilling in best practice of end-of-life care management
  • encourage junior colleagues to participate in multidisciplinary case reviews, mortality and morbidity meetings, 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:

  • ensure that quality end-of-life care management processes are evidence based and outcome focused
  • use systematic reviews or personal reviews and appraisal of the literature, as evidence for the 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 and families or carers
  • develop strategies for identifying culturally appropriate decision makers, and obtain their input in discussions of patients’ end-of-life care
  • offer support to 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:

  • understand, respect, and respond to individual preferences and needs of patients, regardless of their 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:

  • ensure all team members discuss end-of-life care with patients, and act on expressed patient preferences
  • enhance the quality of life for patients before death to minimise pain and suffering caused by ineffective treatments
  • recognise the complexity of ethical issues related to human life and death, when considering the allocation of scarce resources

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
  • ensure patients’ dignity is preserved
  • respond appropriately to distress or concerns of colleagues or patients

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 making treatment decisions
  • liaise with other relevant services, providing referrals as necessary
  • recognise when to involve the coroner

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:

  • ensure care plans are communicated to all teams involved in patients’ care, including relevant community care providers
  • define the roles and responsibilities of team members involved in patients’ care
  • achieve agreement between multidisciplinary teams about patients’ treatment options
  • identify the role of morbidity and mortality meetings and hospital governance
  • coordinate care and support to be provided in patients’ preferred place of care
  • effectively manage personal challenges of dealing with death and grief

direction
Requires some supervision

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

The trainee may:

  • coordinate end-of-life care to minimise fragmentation of care
  • document multidisciplinary care plans, including the terminal phase

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 Health policy, systems, and advocacy
  • allocate resources according to the organisational strategic plan to support systems for effective delivery of end-of-life care
  • advocate for the needs of individual patients, social groups, and cultures within the community who have specific palliative care needs or with inequitable access to palliative care services

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
  • support community-based service providers to build capacity for people to be cared in their preferred place of death