Postgraduate School of Palliative Medicine and Palliative Care

Integrated training objectives (i.e., Common Core):
The trainee must have acquired satisfactory theoretical knowledge and professional competence in the clinical and instrumental diagnosis and treatment, including emergency and urgent conditions, of the most common internal medicine diseases, oncology, and organ system diseases, including chronic degenerative diseases such as pulmonary, neurological, nephrological, cardiac, hematological, orthopedic, gastroenterological, endocrine-metabolic, and rheumatological diseases, as well as infectious diseases, as well as conditions of progressive polymorbidity related to aging.
The trainee must acquire fundamental knowledge of the pathophysiology of the various organs and systems, the theoretical and practical knowledge necessary for recognizing diseases affecting the various body systems, theoretical and practical knowledge of the main areas of instrumental and laboratory diagnostics related to the aforementioned diseases, and the ability to assess the connections and influences of internal medicine and specialists. They must therefore be able to recognize the clinical and functional symptoms and signs of diseases affecting various organs and systems, having acquired the fundamental diagnostic, therapeutic, psychological, and ethical knowledge necessary for a comprehensive patient assessment.
To this end, they must develop the ability to clinically assess the patient based on the medical history and physical examination; develop critical and analytical diagnostic skills; become familiar with the main diagnostic procedures and laboratory and instrumental investigations; recognize and be able to address major medical emergencies; familiarize themselves with therapeutic resources to plan their optimal use and recognize their indications and contraindications, as well as the effects of interactions and potential iatrogenic effects; acquire fundamental knowledge related to clinical research methodologies and pharmacological trials; and understand the fundamental issues related to prevention, public health, and social medicine.
The trainee must have acquired satisfactory theoretical knowledge and professional competence in the recognition and treatment, in emergency situations, of the most common pathologies.
The trainee must also progressively acquire the diagnostic and therapeutic skills necessary for the care and clinical management of complex patients in all phases of chronic, unfavorable-progressing diseases; the ability to communicate clearly and compassionately with patients and families regarding informed consent, possible therapeutic support, and clinical decisions for symptom management, including end-of-life care; the ability to interact with other specialists and other healthcare professionals; skills in healthcare organization and clinical governance; and knowledge of research and evidence-based medicine in various disciplines. They must therefore hone their theoretical knowledge and professional expertise in recognizing and treating advanced stages of illness and end-of-life care, particularly with regard to identifying the timely and progressive transition from active to palliative care. They must also be able to interact effectively with specialists in all phases of the aforementioned diseases, including incurable clinical conditions, having developed particular expertise in assessing and treating conditions characteristic of their advanced stages.

Basic training objectives:
The trainee must deepen and update their knowledge of the evolution of the most common complex and advanced chronic conditions, the pathophysiological correlations between the functional alterations of various organs and systems and the related clinical syndromes and symptoms, as well as knowledge of guidelines for palliative pharmacological treatment. Specifically, they must learn quality-of-life assessment methods, the pathophysiology of pain, the identification and interpretation of the health needs of individuals and their families, and the appropriateness and effectiveness of healthcare interventions. They must also acquire listening, relationship, and interpersonal communication skills, acquire the principles of medical ethics and clinical bioethics, and develop a theoretical and operational approach aimed at interprofessional work.

General training objectives:
The trainee must acquire epidemiological, clinical, psychological, ethical, and managerial knowledge, as well as clinical reasoning methodology, for a comprehensive and unified approach to solving complex health problems; develop clinical reasoning oriented toward problem-based analysis and resolution; understand the short-term prognosis of various pathologies and clinical syndromes; develop critical and analytical diagnostic skills (positive-etiological, etiological, and differential diagnosis), personally designing and evaluating therapeutic pathways; deepen their knowledge of medications, including their pharmacological characteristics, indications, contraindications, and interactions; develop the critical thinking skills necessary to apply scientific research findings to individual cases; be able to apply the methodology of experimental and therapeutic clinical research, as well as epidemiological research; understand the proper use of resources and budgets, and monitor the quality of care; acquire the listening and interpersonal skills necessary to communicate effectively with patients, family members, and other professionals involved in patient care. must learn the ethical principles involved in the medical decision-making process with particular regard to the phases that characterize the end of life.

Educational objectives of the School:
The educational objectives of the Specialization School are divided into the following areas:
1. Palliative care and palliative medicine, based on an understanding of the trajectories of diseases that result in a chronic, degenerative, and progressive process;
2. Principles, definitions, clinical practice, regulatory aspects, and organizational models of palliative care and palliative medicine;
3. Pain and symptom management;
4. Psychosocial and spiritual aspects of care;
5. Ethical and legal aspects;
6. Communication;
7. Teamwork;
8. Management/business intelligence.

Upon completion of the course, the trainee must:
- understand the natural history of major chronic and degenerative diseases;
- understand the definition and fundamental principles of palliative medicine and palliative care (quality of life, early and simultaneous palliative care, and end-of-life care);
- be able to correctly identify the early need for palliative care and place it within the diagnostic and therapeutic framework for various chronic progressive diseases;
- be able to integrate their knowledge with that of specialists in various chronic progressive diseases in order to plan personalized diagnostic and therapeutic pathways based on the evolution of the underlying disease;
- be able to apply their knowledge and skills to terminal situations, including acute and emergency situations;
- know the clinical criteria for indicating a palliative care pathway, including those for eligibility for various care settings;
- know the tools for assessing and measuring specific palliative care needs, particularly symptoms and relevant clinical conditions;
- know how to use prognostic assessment tools and tools to identify patients based on the trajectories of various diseases;
- know how to identify and apply digital healthcare tools through the use of mobile devices and apps to ensure the transition and sharing of information through the management of ICT platforms;
- know how to use multidimensional assessment tools through digitalized systems;
- know how to use integrated business intelligence applications that allow for the measurement of care, performance, and economic indicators (Big Data);
- know how to diagnose and treat pain and other symptoms, complications, and emergencies of all major diseases in their advanced stages;
- know how to recognize refractory symptoms in order to indicate and administer palliative sedation;
- know how to identify patients' complex psychological, social, existential, and spiritual needs;
- know how to manage informed consent, Advance Treatment Directives (ADDs), and Shared Care Planning (PCC);
- understand the fundamentals of palliative care service organization in accordance with regulations and be able to implement palliative care services at a regional level;
- understand the regional organization of the Palliative Care Network;
- be able to identify and enhance the factors that foster teamwork;
- be able to recognize the psychological, social, existential, and spiritual needs of the patient and family, as well as possible psychopathological conditions and the different attitudes and emotional responses to incurable illness and the process of dying;
- be able to communicate and establish a relationship with the patient and family, recognizing the factors that promote empathetic and personalized communication, even when managing difficult communications;
- be able to integrate a multidimensional, non-clinical approach into clinical and healthcare practice, exemplified by the concept of "total pain," highlighting the significant moments in the patient's biography, human experience, and personal journey as fundamental components of the support process;
- be able to recognize the bioethical implications of palliative care, particularly regarding patient information and involvement in therapeutic decisions and the various organizational choices in the care plan;
- understand the fundamentals of clinical and epidemiological research in palliative care and its application to evidence-based care and assistance.

Related, integrative, and interdisciplinary objectives:
The trainee must acquire the ability to improve the quality of life of the patient and their family through the selection of resources, the activation of available resources, and the harmonization of the team's interdisciplinary interventions; the ability to work collaboratively and effectively with the entire team, in compliance with quality care standards; the ability to activate the various structures that comprise the palliative care network, as well as the methods for ensuring integration between residential care facilities and home care units; the ability to actively promote their own well-being and that of the team through risk assessment and the adoption of prevention and protection measures; the ability to apply epistemological and methodological skills and advanced techniques to design and conduct qualitative and quantitative research in the palliative field.

Mandatory professional development activities to achieve the following educational objectives:
- performed care activities in hospice palliative care services, home palliative care units (UCPs), and hospital settings, compiling and countersigning at least 100 medical records of inpatients or outpatients personally cared for; the records must include a complete physical examination that includes, among other things, an assessment of nutritional status;
- conducted at least 50 interviews with the patient and family regarding the diagnosis and progression of the underlying disease, prognosis, treatment plan, palliative treatment options, treatment goals and end-of-life care, and organizational decision-making regarding the care plan;
- actively participated in the management, until death, of at least 50 patients in the terminal phase of their illness;
- participated in the assessment and care and treatment planning of at least 100 patients requiring palliative care in the hospital during the consultation and outpatient phases of palliative care;
- participated in the evaluation and development of multidisciplinary therapeutic-care plans in hospices, in the home-based palliative care unit, and in hospital palliative care services;
- participated in the evaluation of the outcomes of implemented care plans;
- organized one; participated in the evaluation of the management, decision-making, and organizational processes of hospice activities, in the home-based palliative care unit, and in hospital palliative care services;
- contributed to at least 50 nighttime and holiday emergency services;
- participated in at least 50 team meetings for the discussion of hospice patients;
- participated in at least 50 team meetings for the discussion of home-based palliative care unit patients;
- participated in discussions of clinical ethics issues for patients during disease progression, including with regard to diagnostic-therapeutic reconciliation;
- performed 20 multidimensional assessments, including through the use of mobile devices and ICT digital platforms;
- performed 15 home diagnostic tests (ultrasound and/or home radiology);
- performed 15 video visits or remote consultations, including through digital telemedicine platforms;
- indicated and participated in the management of the following palliative therapies or procedures:
a. enteral and parenteral nutrition;
b. parenteral hydration;
c. nasogastric tube placement;
d. paracentesis and pleural, peritoneal, and biliary drainage, nephrostomies, tracheostomies, and other invasive and palliative surgical procedures;
e. oxygen therapy using various modalities (high flow, NIV);
- indicated, discussed with the team, and managed with appropriate monitoring, at least 20 cases of palliative sedation in various settings.

The trainee may apply for the diploma after completing the professional development activities.

As part of their training, the trainee must learn the scientific foundations of the School's approach to achieve full maturity and professional competence. This includes adequate interpretation of scientific innovations and the critical thinking necessary to effectively manage both patient care and their own development. This training may include participation in meetings, conferences, the production of scientific publications, and periods of attendance at qualified Italian and foreign institutions useful for their education.