acknowledgment by practitioners and educators of the compelling need to better prepare clinicians to assess and manage symptoms, to communicate with patients and families, and to participate in interdisciplinary caregiving that meets the varied needs of dying patients and those close to them. Professional organizations including the American Medical Association and the American Board of Internal Medicine have launched major educational initiatives directed at both students and established clinicians, and individual medical schools are redesigning their curricula. Private foundations are supporting a number of curriculum development projects. (Appendixes C, G, and I include materials related to several of these initiatives.) The alumni bulletin of the Harvard Medical School devoted most of its Winter 1997 issue to end-of-life topics including one article on a course, Living with Life-Threatening Illness, that was developed in response to student requests and with a grant from the National Cancer Institute (Block, 1997).

These and other initiatives are promising, but persistence in their implementation, evaluation, redesign, and extension will be necessary to keep the promise from fading once initial enthusiasm subsides. In particular, the clinical elements of end-of-life care require more emphasis. For example, the committee was struck by how many schools for health professionals seem to assign end-of-life issues to ethics seminars and discussions (see, e.g., Dickinson and Mermann, 1996). Certainly, such a foothold may serve as a starting point for drawing attention to difficult clinical choices. The committee believes, however, that it is unwise and unacceptable to segregate death and dying from the rest of the clinical curriculum.

The first part of this chapter, which draws on the discussion in Chapter 3, considers the core elements of professional competence in caring for those approaching death. The rest of the chapter focuses on the undergraduate and graduate education of physicians, nurses, and social workers and also points to the importance of continuing education. The fundamental argument of the chapter is that health professions education can do better in

  1. conferring a basic level of competence in the care of the dying patient for all practitioners;
  2. developing an expected level of palliative and humanistic skills considerably beyond this basic level; and
  3. establishing a cadre of superlative professionals to develop and provide exemplary care for those approaching death, to guide others in the delivery of such care, and to generate new knowledge to improve care of the dying.
  4. The emphasis in this chapter on professional education should not imply lack of concern about what happens in colleges, high schools, grade schools, and homes. Medical education is a powerful, transforming, and



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