ROTATION INFORMATION
DEPARTMENT OF ANESTHESIA
RESIDENCY TRAINING PROGRAM
UNIVERSITY OF MANITOBA
PALLIATIVE CARE MEDICINE
INTRODUCTION
Anesthesia residents may take the opportunity to perform a rotation(s) in palliative
medicine during their residency which will allow for a broad exposure to the care of
terminally ill patients along with their numerous and often times challenging problems.
Along with the BCT year and other Internal Medicine and Subspecialty rotations, this
rotation is designed to allow the residents to:
a)
Develop primary skills (patient assessment, use of laboratory tests, and special
investigations) across a broad range of medical practice.
b)
Develop a mature and effective physician-patient relationship
c)
Participate in the team management of patients and, when appropriate, supervise
more junior members of the team ( the opportunities for these are more limited in
anesthesia rotations)
d)
Acquire both general medical knowledge, and specialty specific knowledge
necessary to function as a competent perioperative physician.
Please refer also to the National Curriculum for Canadian Anesthesia Residency for more
information on expected knowledge and skills.
GOALS AND OBJECTIVES
1. Medical Expert
By the end of this rotation, the resident will be able to perform the following:
A. Describe the biopsychosocial theory of chronic pain and explain the
importance of this in managing the chronic pain patient.
B. Describe the types of pain measurement tools used in chronic pain
management.
C. Explain the difference between nociceptive and neuropathic pain.
D. Discuss the incidence, causes, principals of cancer pain management
E. Identify barriers to cancer pain management
F. Identify therapeutic options for cancer related pain syndromes
G. Discuss the role of radiotherapy, chemotherapy as well as surgery in cancer
pain management.
H. Discuss the role of opioids in chronic pain management
I. Describe the classification and pharmacokinetics of opioid drugs including
agonists, partial agonists, endogenous and antagonist of the opioid system.
J. Appropriately prescribe of NSAIDs, COX-2 inhibitors and acetaminophen,
taking into account the pharmacokinetics, pharmacodynamics, indications and
contraindications.
PENDING REVISION – JULY 2013
Page 1
K. Identify and manage the side effects of NSAIDs, COX-2 inhibitors and
acetaminophen
L. Utilize antidepressants for pain management, taking into consideration the
indication for use, the specific drugs used for the treatment of pain, principles
of dosing antidepressants, and contraindications to different antidepressants.
M. Appropriately prescribe anticonvulsants in the treatment of pain taking into
account indications, the relative efficacy and adverse effects, and the
appropriate dosing regimens for each anticonvulsant and potential toxicities of
these drugs.
N. Discuss the roles and indications of the following adjuvant drugs in the
treatment of cancer pain: neuroleptics, antihistamines, analeptics,
corticosteroids, muscle relaxants/antispasticity drugs, NMDA antagonists,
local anesthetics and membrane stabilizing drugs, sympatholytic drugs,
bisphosphonates and alpha-2 agonists.
O. Discuss peripheral stimulation techniques used to produce analgesia including
TENS, and acupuncture, including the postulated mechanisms of peripheral
stimulation-induced analgesia.
P. Discuss the role of local anesthetic/neurolytic nerve blocks in cancer pain
management.
Q. Discuss the role of surgical procedures in the management of pain including:
peripheral neurectomy, sympathectomy, spinal dorsal rhizotomy, cordotomy,
dorsal root entry zone procedures, commissural myelotomy, and facet
rhizolysis.
R. Appropriately prescribe and administer neuraxial opioids taking into
consideration the indications, contraindications, side effects, and relative
differences between opioids.
S. Manage the following symptoms, and provide a rationale based in the
pathophysiology of the symptoms and associated syndromes
i. Dyspnea
ii. Delirium
iii. Nausea and vomiting
iv. Constipation
v. Anxiety and depression
vi. Decubitus ulcers
T. Diagnose and manage the following intercurrent medical problems in the
palliative patient and provide a rationale based on the pathophysiology
i. Hypercalcemia
ii. Spinal cord compression
iii. SVC syndrome
iv. Pathologic fractures
v. Seizures
vi. hemorrhage:
2. Communicator
A. Obtain a history that identifies
i. The sources and types of pain and adverse symptoms, impediments
to treatment, and biopsychosocial impacts
PENDING REVISION – JULY 2013
Page 2
3.
4.
5.
6.
7.
ii. All of the medical, surgical and biopsychosocial issues facing the
individual patient
B. Inform patients and families about therapies, options, the current and
projected course of their illness in a manner that minimizes psychological
distress
C. Obtain informed consent for all treatments undertaken
D. Establish and effective therapeutic relationships with patients and families
E. Clearly determine the wishes of the patient with respect to degrees of
intervention as illness progresses
F. Recognize and coordinate access to support for bereavement and grief in
patients in families
Collaborator
A. Identify the need for and coordinate access to psychological and spiritual
support in the management of the palliative care patient.
B. Identify the roles of, and coordinate access to medical and surgical
consultants, allied health, rehabilitation services, and complementary
medicine
C. Liaise effectively with referring physicians, allied health professionals, and
consultants
D. Contribute as a member and leader, to multidisciplinary care rounds
Manager
A. Coordinate access to psychological support, physiotherapy, occupational
therapy and other allied health services as needed
B. Recognize and manage the challenges of home and outpatient management of
palliative care
Health Advocate
A. Identify and intervene to address systemic impediments to provision of safe
and effective, patient-centered palliative care
Scholar
A. Apply principles of evidence-based practice to palliative care
Professional
A. Adhere to all professional expectations as outlined in the overall program
Goals and Objectives
CLINICAL RESPONSIBLITIES
Ward management
The resident will be expected to take a leading role in the organization and function of the
care team, as well as function as the primary physician for patients assigned to him/her.
The details of schedules and locations will vary with the site assignment and will be
handed out separately.
Pain and Symptom Clinics
The resident will be expected to attend all Pain and Symptom clinics.
OTHER RESPONSIBILITIES
Journal Club
PENDING REVISION – JULY 2013
Page 3

The Resident is expected to attend all of the twice weekly journal club
meetings that occur during their rotation
 The Resident will review and present at least one article at a journal club
meeting over the course of the rotation
Palliative Care Rounds
The resident is expected to attend weekly Palliative care rounds.
PENDING REVISION – JULY 2013
Page 4