Cosco and colleagues deserve accolades for their article in CMAJ.1
Although there may be many factors that have led to the development of a death-denying culture, we believe that the main driver relates to deficiencies within medical education. Medical curricula are driven by competency frameworks. During the early 1990s, the Royal College of Physicians and Surgeons of Canada created the Canadian Medical Education Directives for Specialists (CanMEDS).2 With an aim to improve patient care and outcomes in a continuously evolving health care environment, this globally recognized framework encompasses 7 essential roles (competencies) all physicians must fulfill to be effective health care providers: medical expert, communicator, collaborator, manager, health advocate, scholar and professional. The CanMEDS framework serves as an integral part of Canadian medical education and practice, as it forms the basis for the training objectives of all medical specialties and subspecialties recognized by the Royal College.2 Currently, the framework is undergoing a 3-year reform with the goal of aligning with a competency-based approach to medical education by 2015.2
We conducted a content analysis of the CanMEDS Objectives of Training in the Subspecialty of Geriatric Medicine (2012, Version 1.0) using Foxit Reader 5.1 software. We scanned the document for keywords that are pertinent to the delivery of timely palliative care services to geriatric patients. Only brief mention of “end of life care,” “end-of-life care,” and “prognostic factors” are found in the “Medical Expert” section. Completely absent are the following keywords: prognosis, prognosticate, prognostication, life expectancy, survival estimate, natural history of disease, palliative, palliation and palliative care. None of the aforementioned keywords were found within the sections that outline the other 6 roles.
For palliative care to be delivered in a timely fashion, physicians must skillfully discuss the diagnosis and natural history of the disease, together with the formulation of a prognosis and the communication of that prognosis to the patient and/or substitute decision-maker. In a truly patient-centred manner, the patient and/or substitute decision maker may then choose either to proceed with an active, aggressive medical micromanagement mode or a conservative palliative mode (i.e., pain and symptom management).3
The deathless models of aging described by Cosco and colleagues1 represents an epiphenomenon that we believe is the result of deficiencies within medical education. It behooves competency frameworks such as Can-MEDS to incorporate competencies that will enable the timely transitioning of patients toward conservative palliative philosophies of care that promote comfort, dignity, quality of life and quality of death. At the root of this process is the restoration of prognosis as a core competency in medical practice.