attention (directly or by cross-reference) to the care of dying patients and their families.

Changing health professions education is not easy. Deans of health professional schools, department chairs, residency program directors, certification and accreditation bodies, textbook authors, and other leaders face an avalanche of demands for new topics or perspectives to be included in curricula, residency program requirements, and other elements of health professions education. Academic medical centers and medical, nursing, and other health professions schools or programs also face financial pressures, particularly when state governments are trimming health and education budgets.

Change often requires a years-long process of developing, reviewing, ratifying, and implementing new educational requirements or methods. For example, a change in residency requirements usually involves years of preparation, discussion, negotiation, and review before adoption, which is then followed by more time to allow implementation before programs are assessed for compliance. Changing course offerings and requirements in a medical or nursing school, particularly adding a requirement, is often a highly political process as different disciplines compete for priority in an already overloaded curriculum. Thus, those promoting educational reforms may also pursue less formal strategies such as persuading individual instructors to include palliative care issues as illustrations in existing courses.

Efforts to improve the education of health professionals in palliative and end-of-life care can take several forms. They can include actions to

• improve curricula, clinical experiences, or resources (e.g., faculty preparation) for single educational institutions or programs or for consortia of institutions;

• set curriculum or other standards for a category of educational institutions, programs, or professionals;

• develop faculty expertise and other educational resources, including textbooks and Internet sites; and

• expand educational opportunities available to practicing professionals.

Some initiatives focus on the development of materials or models that have general application across institutions, for example, standards for