PGY-1 Training Objectives
Training Objectives for Psychiatry PGY-1 Year
Department of Psychiatry, University of Ottawa
June 2007
Preamble
The PGY-1 program gives recently graduated medical students the opportunity to put into practice the theoretical knowledge they gained in medical school and to enhance the clinical experiences from their clerkship. Training consists of 13 separate four week rotations that begin with the academic year every July 1st.
The primary purpose of the PGY-1 year is to ensure that residents have a broad and thorough exposure to a variety of rotations while keeping in mind that their ultimate career choice is psychiatry. Training in psychiatry becomes less and less "medical" as residents advance. By the time they have completed their core requirements, residents are usually interested in spending their electives in subspecialty areas of psychiatry, not re-establishing medical skills. For this reason, the PGY-1 program is of utmost importance in developing a broad base of medical skills because it may well be the last opportunity for residents to work outside of a psychiatric setting. The expertise gained during PGY-1 benefits residents during their entire training, and is of particular assistance during their future consultation-liaison rotations.
"The identity and role of the psychiatrist evolves from that of physician, and it remains important to maintain an active medical knowledge and skill level appropriate to one's practice profile and location. A broad objective for the PGY-1 curriculum is to develop an understanding of the knowledge base, skill sets, and complexities of medical practice across as wide a sample of medical specialties as possible." (COPE, 1999/2000)
Composition of the PGY-1 Curriculum
The composition of the PGY1 Curriculum is decided by our Postgraduate Education Committee and is in keeping with current guidelines from the Royal College Specialty Committee in Psychiatry and COPE. The current composition is listed below and is reviewed annually.
- Psychiatry - General Adult Inpatient
- Psychiatry - Emergency
- Psychiatry - Addictions
- Psychiatry Underserviced (A number of opportunities either hospital or community-based in the Ottawa Region or in Northern Ontario)
- Internal Medicine
- Neurology
- Geriatric Medicine
- Neuroradiology x 2 weeks / Cognitive Disorders x 2 weeks (to be confirmed)
- Family Medicine
- Emergency - Adult
- Emergency - Pediatrics
- Endocrinology
- Palliative Care
PGY-1 General Goals & Objectives
(based on guidelines from COPE 2000 and Royal College Specialty Committee in Psychiatry 2001)
1) The purpose of training is to give the resident a degree of independent responsibility for clinical decisions.
2) An opportunity for further development of skills required to make effective relationships with patients and other health professionals.
3) Develop an understanding of the nature of the relationship between a referring physician and consulting specialist.
4) The consolidation of competence across a broad range of medical practice.
5) Development of an understanding of the knowledge base, skill set, and complexities of medical practice across as wide a sample of medical specialties as possible.
6) Consolidation of general medical knowledge as it is applicable to the practice of psychiatry. 7) Continued development of medical ethics.
8) Continued development of understanding patients' response to illness.
9) Continued understanding of the doctor-patient relationship.
10) Application and development of CanMEDS roles.
11) Continued development of independent decision making in the context of working with colleagues in different disciplines and at different levels of training.
Additional Training Objectives
1) Career counseling (exposure to the major subspecialties in psychiatry).
2) Introduction to the Department of Psychiatry and an awareness of its resources and personnel.
3) Adequate clinical exposure for LMCC/MCCQE Part II exam preparation.
4) Recruitment and retention considerations.
5) Portability of licensure between provinces.
6) Sufficiently generic to allow transfer to other specialty programs.
7) Provide flexibility for individual interests and career goals of the resident.
CanMEDS Objectives for PGY-1 Rotations
CanMEDS Role: Medical Expert, Part I - Knowledge and Understanding of Basic and Clinical Sciences
1) Demonstrates an understanding of physiology, neuroanamtomy, genetics, neurochemistry, and general medical principles
2) Understands normal and abnormal development
3) Aware of phenomenology, symptom recognition, competent differential diagnosis construction, and shows facility with diagnostic nomenclature
4) Knowledge of the etiology, course, and prognosis of general medical conditions
5) Aware of culture, gender, and age-specific theoretical, clinical, and therapeutic issues
6) Demonstrates effective doctor-patient relationships and understands both the theoretical and practical aspects
7) Competence with prescribing medications and physical treatments
8) Understands health regulations, confidentiality, privilege, and other medicolegal issues
9) Facility with critical appraisal, scientific method, quality assurance (QA), and epidemiology
CanMEDS Role: Medical Expert, Part II - Skills/Ability to recognize and treat a wide range of medical disorders in a variety of clinical contexts.
1) Establishes and maintains effective working relationships with patients
2) Conducts and organizes a coherent, appropriate interview
3) Arrives at a reasonable provisional/preferred diagnosis based on the information collected, and constructs a list of differential diagnoses
4) Develops and implements an integrated treatment plan
5) Maintains accurate and complete medical records
6) Overall proficiency with technical and procedural skills; minimizes the risks and discomfort to the patient
CanMEDS Role: Communicator
1) Listens effectively
2) Ability to convey to patients and families an accurate and coherent understanding of the diagnosis, treatment plan, and prognosis
3) Discusses appropriate information with the health care team
4) Document preparation is accurate and timely
CanMEDS Role: Collaborator
1) Consults effectively with other physicians and health care professionals
2) Ability to teach colleagues, and willingness to learn from them
3) Ability to work collaboratively with other members of the health care team; recognizes their roles and responsibilities; contributes to team activities
4) Ability to facilitate the learning of patients, students, and other health care professionals
CanMEDS Role: Health Advocate
1) Awareness of structures of governance in health care
2) Awareness of major regional, national, and international advocacy groups
3) Identifies and understands the determinants of health as it affects patients and communities; responds appropriately in advocacy situations
CanMEDS Role: Manager
1) Makes effective use of information technology to optimize patient care, lifelong personal learning, and other activities
2) Evaluates the effective use of resources
3) Directs patients to appropriate community resources
4) Able to set realistic priorities and uses effective time management skills
5) Coordinates the efforts of the health care team
CanMEDS Role: Scholar
1) Commitment to the need for lifelong learning; develops and implements an ongoing and effective personal learning strategy
2) Critically appraises the medical literature; successfully integrates information from a variety of sources
3) Helps others learn through guidance, teaching, and constructive feedback
4) Awareness of the clinical application of research principles
CanMEDS Role: Professional
1) Demonstrates integrity, honesty, compassion, and respect for diversity
2) Fulfills medical, legal, and professional obligations of a physician
3) Responsibility, dependability, self-direction, and punctuality
4) Acceptance and constructive use of supervision and feedback
5) Awareness of the application of ethical principles
6) Awareness of personal limitations and appropriate action when confronted with these limitations
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PGY-1 Rotation-Specific Objectives
Psychiatry - General Adult Inpatient
1) Exposure to inpatient settings, and to participate in the investigation and treatment of general adult psychiatric conditions.
2) Establish a basis for distinguishing psychiatric conditions from medical illness based on history and development of appropriate differential diagnoses.
3) Demonstrate competence in determining appropriate investigations to differentiate psychiatric conditions from physical illness.
4) To learn about the appropriate use of pharmacological agents in general adult psychiatric patients.
5) To develop an appreciation for the biopsychosocial approach to understanding psychiatric conditions.
6) To be exposed to general adult psychiatrists who can provide both guidance for future rotations and career counseling.
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Emergency Psychiatry
1) Demonstrate an understanding of the method of consultation and role of the psychiatric consultant in emergency or acute situations.
2) Demonstrate an understanding of the phenomenology, epidemiology, natural history, course and comorbidity of psychopathological conditions presenting in the emergency room.
3) Demonstrate an understanding of biological, psychological, social and cultural factors involved in the etiology, prognosis, and course of acute disorders, especially noting those factors which determine presentation to the emergency room.
4) Recognize the bio-psycho-social factors involved in the presentation of and /or the request for consultation in violent patients, suicidal patients, substance and alcohol abusing patients, behavioral crisis, and family crisis.
5) The evaluation, triage, treatment and disposition of the full range of psychiatric disorders presenting in the emergency room where immediate intervention is required. This includes capacity to do risk assessments in suicidal or violent patients.
6) Identify acute organic conditions requiring medical or psychiatric intervention including drug and alcohol intoxication/overdose/withdrawal and delirium in the emergency room.
7) Be aware of community and hospital resources and be able to access or refer patients to the range of available hospital and community resources in an appropriate manner.
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Psychiatry Addictions
This rotation takes place at the Royal Ottawa Hospital Addictions Unit, and is primarily outpatient-based.
1) Demonstrate sufficient knowledge to describe the etiology, clinical presentations, differential diagnosis and treatment of alcohol abuse and dependence; substance abuse and dependence; and the interaction between these and affective disorders, anxiety disorders, psychotic disorders, and compulsive disorders
2) Demonstrate the ability to do a comprehensive biopsychosocial assessment of a patient with an alcohol abuse/dependence and/or substance abuse/dependence problem referred to the Addiction Program from the community.
3) Demonstrate the ability to do a comprehensive biopsychosocial and psychiatric assessment of a dually diagnosed patient (substance abuse and a psychiatric order)
4) Demonstrate knowledge of the psychopharmacology relevant to treating alcohol and drug dependent patients and those with dual disorders. This includes rolls of naltrexone, methadone, benzodiazepine titration, disulfiram. It also includes the use of antidepressants in recovering patients with affective and anxiety disorders.
5) Develop an understanding of the resources available for treating alcohol and drug abuse, both in hospital and in the community.
6) Demonstrate capacity to work collaboratively with a multidisciplinary addiction treatment team.
7) Learn and demonstrate techniques for engaging patients in the treatment process.
8) Demonstrate an understanding of the principles of physical dependence and withdrawal and demonstrate the capacity to diagnose and manage these conditions.
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Psychiatry Underserviced
There are two types of underserviced rotations available:
A. Underserviced Geographic Area
1) To offer exposure to geographic areas in the province that are considered under-serviced by psychiatrists.
2) To develop awareness of the psychiatric care needs for areas outside of urban centers.
3) To appreciate the many pressures on family physicians and other mental health care providers in under-serviced areas
4) To potentially attract residents to work in under serviced areas
B. Underserviced Specialty within Psychiatry
1) To offer exposure to fields in psychiatry that have few specialists provincially/nationally and that are not necessarily covered in the senior years of training. Examples would be Eating Disorders, Forensics, Developmental Disorders, as well as Dual Diagnosis Disorders such as Psychiatric illness comorbid with Developmental Disorder or Substance Abuse.
2) To increase the knowledge and capacity to diagnose and manage patients with such disorders.
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Internal Medicine
The Internal Medicine rotation is done at the general medical inpatient wards at the General or Civic Campus.
Goals and Objectives
1) Exposure to general inpatient and outpatient medical illnesses, and participate in their investigation and treatment.
2) Establish a basis for distinguishing psychiatric from medical illness based on history and development of appropriate differential diagnoses.
3) Demonstrate competence in physical examination skills sufficient to differentiate psychiatric conditions from physical illnesses.
4) Demonstrate competence in determining appropriate investigations to differentiate psychiatric conditions from physical illnesses.
5) To learn about the general medical uses of pharmacological agents that are used in psychiatry.
6) To learn how to manage common medical problems that are likely to be comorbid in psychiatric patients, and to develop the ability to address lifestyle factors that impact on the long-term prognosis of both medical and psychiatric illnesses (i.e. obesity, hypertension, diet, exercise, hygiene, smoking, alcohol consumption, substance misuse).
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Neurology
1) Exposure to general neurological illness and participating in their investigation and treatment.
2) Establish a basis for being able to distinguish psychiatric from neurological illness based on history and development of appropriate differential diagnoses.
3) Demonstrate competence in physical examination skills sufficient to differentiate psychiatric conditions from neurological illness.
4) Demonstrate competence in determining appropriate investigations to differentiate psychiatric conditions from neurological illnesses.
5) To learn about the neurological uses of pharmacological agents that are used in psychiatry (i.e. anticonvulsants).
6) To learn how to manage common neurological problems that are likely to be comorbid in psychiatric patients (i.e. movement disorders).
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Geriatric Medicine
1) Exposure to medical illnesses presenting in elderly inpatients with opportunity to participate in their investigation and treatment.
2) Establish a basis for distinguishing psychiatric from medical illness presenting in the elderly based on history and development of appropriate differential diagnoses.
3) Demonstrate competence in physical examination skills sufficient to differentiate psychiatric conditions from physical illnesses presenting in the elderly.
4) Demonstrate competence in determining appropriate investigations to differentiate psychiatric conditions from physical illnesses in the elderly.
5) To learn pharmacological considerations specific to older adult patients.
6) Identify and assess dementia and delirium which commonly presents in the elderly.
7) To learn how to manage common medical problems that are likely to be co-morbid in elderly psychiatric patients, and to develop the ability to address lifestyle factors that impact on the long-term prognosis of both medical and psychiatric illnesses (i.e. obesity, hypertension, diet, exercise, hygiene, smoking, alcohol consumption, substance misuse).
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Neuroradiology
1) To understand the diagnostic usefulness (and limitations) of enhanced and unenhanced CT and MRI in patient care.
2) To utilize CT and MRI appropriately to assist in diagnosing organic illness verses primary psychiatric illness particularly in acute care settings such as the emergency room or C/L psychiatry.
3) To enhance knowledge of neuroanatomy.
4) To review the current research literature in psychiatry and neuropsychiatry that utilizes neuroradiology imaging including PET scan studies.
5) To understand and appreciate the cost/benefit issues of neuroradiology imaging when determining appropriate investigations in patient care.
6) To enhance knowledge of interventional neuroradiology such as cerebral aneurysm coiling.
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Family Medicine
Family Medicine Rotation is done either at the General-Bruyere Family Medicine Centre or the Civic-Melrose Clinic.
Goals and Objectives
1) Exposure to primary care / family physician settings to develop an understanding and appreciation of the multitude of issues facing primary care practitioners. This is particularly relevant for the development of skills necessary for a psychiatrist to work in a "Shared Care Model".
2) To enhance the development of psychiatry consultation skills to better meet the needs of Family Physicians.
3) Exposure to patients presenting with medical illnesses in primary care settings and participating in their investigation and treatment.
4) Establish a basis for being able to distinguish psychiatric from medical illness based on history and development of appropriate differential diagnoses.
5) Demonstrate competence in physical examination skills sufficient to differentiate psychiatric conditions from physical illnesses.
6) Demonstrate competence in determining appropriate investigations to differentiate psychiatric conditions from physical illnesses in the primary care setting.
7) To learn about the general medical uses of pharmacological agents that are used in psychiatry.
8) To learn how to manage common medical problems that are likely to be comorbid in psychiatric patients and to develop a facility with addressing lifestyle factors that impact on the long-term prognosis of both medical and psychiatric illnesses (i.e. obesity, hypertension, diet, exercise, hygiene, smoking, alcohol consumption, substance misuse).
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Emergency - Adult
1) Exposure to general adult medical/surgical illness in an emergency setting and participate in their investigation and treatment.
2) Establish a basis for being able to distinguish psychosomatic and other psychiatric conditions from general medical/surgical illnesses based on history and development of appropriate differential diagnoses.
3) Demonstrate competence in physical examination skills sufficient to differentiate psychosomatic and other psychiatric conditions from medical/surgical illnesses.
4) Demonstrate competence in determining appropriate investigations to differentiate psychosomatic and other psychiatric conditions from general medical/surgical illnesses.
5) To learn about the management of urgent and emergent psychiatric situations (i.e. use of sedatives, parenteral agents, restraints, etc.).
6) To learn how to manage common emergencies that are likely to occur in psychiatric patients (i.e. basic life support, advanced cardiac life support, trauma management, wound management including suturing and hemostasis, management of overdoses, basic toxicology, appropriate referral to other medical specialties, etc.).
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Emergency - Pediatrics
1) Exposure to general child medical/surgical illness in an emergency setting and participate in their investigation and treatment.
2) Establish a basis for being able to distinguish psychosomatic and other psychiatric conditions from general medical/surgical illnesses based on history and development of appropriate differential diagnoses.
3) Demonstrate competence in physical examination skills sufficient to differentiate psychosomatic and other psychiatric conditions from medical/surgical illnesses.
4) Demonstrate competence in determining appropriate investigations to differentiate psychosomatic and other psychiatric conditions from general medical/surgical illnesses.
5) To learn about the management of urgent and emergent psychiatric situations (i.e. use of sedatives, parenteral agents, restraints, etc.).
6) To learn how to manage common emergencies that are likely to occur in psychiatric patients (i.e. basic life support, advanced cardiac life support, trauma management, wound management including suturing and homeostasis, management of overdoses, basic toxicology, appropriate referral to other medical specialties, etc.).
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Endocrinology and Metabolism
Goals and Objectives
During the Endocrine rotation, PGY-1 Residents in the Psychiatry Program will:
Medical Expert/Clinical Decision Maker
1) Obtain and demonstrate skill appropriate for PGY-1 level in the ambulatory management of patients with:
- Diabetes Mellitus Types I & 2
Thyroid Disease
Lipid Disorders
Osteoporosis
Pituitary and Hypothalamic disorders Adrenal Disorders
2) Develop skills appropriate for PGY-1 level in the diagnosis and treatment of other endocrine disorders including:
polycystic ovary disease
androgen excess syndromes in females
Disorders of testicular function including infertility and hypogonadism
Calcium abnormalities and bone metabolism (abnormalities)
3) Understand the proper interpretation of laboratory and radiological investigations relevant to endocrinology.
4) Establish a basis for distinguishing psychiatric from endocrine illness based on history, investigations and development of appropriate differential diagnoses
5) Demonstrate competence in physical examination skills sufficient to differentiate psychiatric conditions from physical illnesses
6) Demonstrate competence in determining appropriate investigations to differentiate psychiatric conditions from physical illnesses
7) To learn how to manage common endocrine medical problems that are likely to be co-morbid in psychiatric patients, and to develop the ability to address lifestyle factors that impact on the long-term prognosis of both medical and psychiatric illnesses (i.e. obesity, hypertension, diet, exercise, hygiene, smoking, alcohol consumption, substance misuse)
Communicator
1) Document and present in an orderly and competent manner the clinical findings, problem synthesis, and appropriate management plan for clinic patients with endocrine disorders.
2) Discuss the significance of this information with patients and families and elicit the patients' preferences with regards to treatment decisions
3) Understand the importance of patient education in the management of many common medical conditions and facilitate such learning when and wherever possible.
4) Dictate effective consultation letters if requested by supervising staff in a timely way that communicate the opinion and specific management plans to the referring physicians and other members of the health care team.
Scholar
1) Utilize the patient encounter as a stimulus to further reading and review of the current literature.
2) Recognize the requirement for self assessment , and the critical role of self directed learning in continuing medical education.
Collaborator
1) Acknowledge the importance of the multi-disciplinary approach required in the management of endocrine disorders and foster respect for and appreciation of the importance of communication with allied health care workers and referring physicians in the care of patients.
2) Work effectively with nurses, nutritionists, patient educators, laboratory physicians, and surgeons to provide optimal and patient outcomes.
Manager
1) Coordinate in an effective manner the ambulatory care of patients with diabetes, thyroid disease, lipid disorders, etc.
2) Investigate and manage patients with endocrine disorders in a cost effective manner, while ensuring the optimal patient care and outcome.
Health Advocate
1) Appreciate patient autonomy and the religious, ethnic, and psycho social factors which influence the physician/patient relationship and to take these factors into account when pursuing problems and understanding patient decisions.
2) Identify and utilize appropriate interventions to treat selective endocrine disorders including diabetes, lipid disorders, and osteoporosis.
Professional
1) Demonstrate effective ethical medical care in a professional manner.
2)Demonstrate appropriate professional behaviour and interpersonal skills.
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Palliative Care
Locations:
Palliative Care Program - Élisabeth Bruyére Health Centre
The Ottawa Hospital (TOH) Palliative Care Consultation Services may also be potential learning sites
Overview of Rotation:
The one month rotation for Psychiatry residents will be based at the Élisabeth Bruyère site of the SCO Health Service. The residents will be assigned to the Palliative Care Unit (PCU), a 36-bed acute in-patient palliative care unit staffed by an interprofessional team of health care professionals and volunteers. More than 400 patients with advanced terminal illness are admitted to the PCU per year for symptom management and/or care in the last stages of life. Approximately 90 % of admitted patients have cancer diagnoses. If the resident has a particular interest in the community consultation serve (the Palliative Pain and Symptom Management Community Consultation Service or PPSMCS) arrangements can be made to facilitate some part of the rotation being spent with this service. The Community Consultation Service, a Nurse/Physician Team coordinated by an Advanced Nurse Practitioner, provides over 500 palliative care consultations a year to patients in their homes, hospices, long term care facilities and residential care.
If the Psychiatry resident has a particular interest in palliative care in acute care facilities, it is possible to have the rotation based at TOH. The Consultation Services of TOH are Nurse/Physician Teams who provide palliative care consultations to in-patients at both the Civic and General Campuses. More than 1000 consultations are provided yearly to patients experiencing pain and other symptoms associated with end-of-life care. Out-patient Palliative Medicine Clinics staffed by the Palliative Care Consultation Team are held weekly at both the Civic and General Cancer Clinics. Over 600 patient visits occur annually with pain and symptom control the main reasons for referral.
Orientation to the Élisabeth Bruyère site includes resource information related to the palliative management of patients. Journal Club is held weekly and trainees are also included in the various rounds and teaching sessions that are a regular function of the Palliative Care Program. Residents are also expected to attend the Palliative Medicine Resident Academic Half Day seminars held weekly during their rotation. While on the PCU, the trainee provides the day-to-day care for patients as part of the interdisciplinary team and participates in the home on-call duty roster. Supervision is by one of the staff palliative medicine physicians. If the resident is interested, there are opportunities for trainees to participate in the community consultation service.
Goals and objectives
The overall goals of the rotation are:
1. To provide psychiatry residents with an understanding of the role of palliative care in the medical management of patients.
2. To provide psychiatry residents with the knowledge and skills to care for the palliative needs of patients and their families.
Educational Objectives:
General objective #1: Medical Expert and Communicator
The resident will be able to demonstrate a person-centred approach for dying patients and their families.
Specific objectives:
1.1 describe the physical, psychological, social and spiritual issues of dying patients and their families;
1.2 demonstrate an ability to work with the patient and family to establish common, patient-centred goals of care;
1.3 demonstrate effective communication skills in dealing with terminally-ill patients and their families, including skills in delivering bad news; and
1.4 demonstrate an ability to support the families of dying patients.
General objective #2: Medical Expert
The resident will be able to demonstrate effective knowledge, skills and attitudes in dealing with the complex interplay of physical, psychological, social and spiritual needs of dying patients and their families.
Specific objectives:
2.1 assess and manage pain effectively, using pharmacological and non-pharmacological approaches;
2.2 assess and manage dyspnea effectively, using pharmacological and non-pharmacological approaches;
2.3 assess and manage nausea and vomiting and malignant bowel obstruction effectively, using pharmacological and non-pharmacological approaches;
2.4 assess and manage constipation effectively, using pharmacological and non-pharmacological approaches;
2.5 assess and manage agitation and delirium effectively, using pharmacological and non-pharmacological approaches;
2.6 identify psychological issues associated with life-threatening illnesses and strategies for addressing them;
2.7 identify the social and existential needs confronting dying patients and their families and strategies for addressing them;
2.8 demonstrate the effective care of the patient and family during the last hours of life; and
2.9 demonstrate skills in working with and caring for families of dying patients.
General objective #3: Collaborator and Communicator
The resident will be able to collaborate as an effective member of an interdisciplinary team.
Specific objectives:
3.1 describe the roles of other disciplines in providing palliative care;
3.2 participate in the interdisciplinary care of patients, including family conferences and team meetings; and
3.3 communicate effectively with other team members.
General objective #4: Collaborator and Communicator
The resident will be able to consult effectively with other physicians and health care providers.
Specific objectives:
4.1 demonstrate the appropriate use of consultative services in providing care for dying patients and their families; and
4.2 demonstrate effective consultation and communication skills when working with colleagues providing and/or requesting consultations.
General objective #5: Health Advocate and Medical Expert
The resident will be able to demonstrate the ability to incorporate accepted standards of palliative care in his/her practice.
Specific objectives:
5.1 develop a proactive approach to addressing the dying patient's and family's expectations and needs.
General objective #6: Professional
The resident will demonstrate awareness of his/her personal issues and concerns with respect to death and dying.
Specific objectives:
6.1 describe his/her own concerns about caring for dying patients and their families;
6.2 demonstrate awareness of how his/her own personal experiences of death and dying have influenced attitudes; and
6.3 discuss methods of managing his/her own stress associated with caring for dying patients.
General objective #7: Professional
The resident will be able to discuss ethical issues confronting dying patients, their families and their professional health care providers, including end-of-life decision-making, advance directives, care planning, competency, euthanasia and assisted suicide.
Specific objectives:
7.1 outline a general framework for ethical decision-making;
7.2 describe an approach to addressing particular ethical issues at the end-of-life; and
7.3 demonstrate integrity, honesty and compassion in the care of patients and families.
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