A survey of competencies and concerns in end-of-life care for physician trainees

Interactive Palliative and End-of-Life Care Modules for Pediatric Residents

Background. There is a need for increased palliative care training during pediatric residency. Objective. In this pilot study, we created a comprehensive experiential model to teach palliative care skills to pediatric residents. Our Comfort Care Modules (CCMs) address pediatric palliative care (PPC) topics of breaking bad news, dyspnea, anxiety, pain management, and the dying child. We also evaluated a scoring system and gathered qualitative data. Methods. The CCMs are part of the University of California San Diego pediatric residency's second-year curriculum. Comparisons were made for statistical trends between residents exposed to the modules (n = 15) and those not exposed (n = 4). Results. Nineteen of 36 residents (52%) completed surveys to self-rate their preparedness, knowledge, and confidence about PPC before and after the intervention. Resident scores increased in all areas. All improvements reached statistical significance except confidence when breaking bad news. Overall, the resident feedback about the CCMs was positive. Conclusions. This study demonstrates that the CCMs can be performed effectively in an academic setting and can benefit residents' self-perception of preparedness, confidence, and knowledge about pediatric palliative care. In the future, we plan to implement the modules on a larger scale. We encourage their use in interprofessional settings and across institutions.

A Pilot Study of Palliative Care Provider Self-competence and Priorities for Education in Kenya

This study explored palliative care provider self-competence and priorities for future education in an inpatient hospice setting in Kenya. Self-competence scores for clinical skills and patient and family communication skills were hypothesized to differ according to provider type. A descriptive, cross-sectional study design was piloted at Kimbilio Hospice, a 26-bed rural, inpatient facility in Kenya. A quantitative survey instrument entitled, "Self assessment of clinical competency and concerns in end-of-life care," was administered to participants. Survey responses were collected from 5 clinical staff, 11 caregivers, and 8 support staff. Data were analyzed using Kruskal-Wallis test to compare between mean scores. Statistically significant differences were found in 5 self-competence variables: performing a basic pain assessment, use of oral opioid analgesics, assessment and management of nausea/vomiting and constipation, and discussing an end-of-life prognosis with a patient's family member (P < .05). Sixteen participants (66%) selected pediatric palliative care as their top priority for future education. The findings support the hypothesis that palliative care providers have varying levels of self-competence. Improving education to build palliative care competencies in adult and pediatric palliative care in sub-Saharan Africa is recommended.

The effectiveness of the Geritalk communication skills course: a real-time assessment of skill acquisition and deliberate practice

BACKGROUND

Communication skills are critical in Geriatrics and Palliative Medicine because these patients confront complex clinical scenarios. We evaluated the effectiveness of the Geritalk communication skills course by comparing pre- and post-course real-time assessment of the participants leading family meetings. We also evaluated the participants' sustained skills practice.

MEASURES

We compare the participants' skill acquisition before and after Geritalk using a direct observation Family Meeting Communication Assessment Tool and assess their deliberate practice at follow-up.

INTERVENTION

First-year Geriatrics or Palliative Medicine fellows at Mount Sinai Medical Center and the James J. Peters Bronx VA Medical Center participated in Geritalk.

OUTCOMES

Pre- and post-course family meeting assessments were compared. An average net gain of 6.8 skills represented a greater than 20% improvement in use of applicable skills. At two month follow-up, most participants reported deliberate practice of fundamental and advanced skills.

CONCLUSIONS/LESSONS LEARNED

This intensive training and family meeting assessment offers evidence-based communication skills training.

Development, implementation and evaluation of a pain management and palliative care educational seminar for medical students

BACKGROUND

Despite calls for the development and evaluation of pain education programs during early medical student training, little research has been dedicated to this initiative.

OBJECTIVES

To develop a pain management and palliative care seminar for medical students during their surgical clerkship and evaluate its impact on knowledge over time.

METHODS

A multidisciplinary team of palliative care and pain experts worked collaboratively and developed the seminar over one year. Teaching methods included didactic and case-based instruction, as well as small and large group discussions. A total of 292 medical students attended a seminar during their third- or fourth-year surgical rotation. A 10-item test on knowledge regarding pain and palliative care topics was administered before the seminar, immediately following the seminar and up to one year following the seminar. Ninety-five percent (n=277) of students completed the post-test and 31% (n=90) completed the follow-up test.

RESULTS

The mean pretest, post-test and one-year follow-up test scores were 51%, 75% and 73%, respectively. Mean test scores at post-test and follow-up were significantly higher than pretest scores (all P<0.001). No significant difference was observed in mean test scores between follow-up and post-test (P=0.559), indicating that students retained knowledge gained from the seminar.

CONCLUSIONS

A high-quality educational seminar using interactive and case-based instruction can enhance students' knowledge of pain management and palliative care. These findings highlight the feasibility of developing and implementing pain education material for medical students during their training.

Race, income, and education: associations with patient and family ratings of end-of-life care and communication provided by physicians-in-training

BACKGROUND

Minority race and lower socioeconomic status are associated with poorer patient ratings of health care quality and provider communication.

OBJECTIVE

To examine the association of race/ethnicity or socioeconomic status with patients' and families' ratings of end-of-life care and communication about end-of-life care provided by physicians-in-training.

METHODS

As a component of a randomized trial evaluating a program designed to improve clinician communication about end-of-life care, patients and patients' families completed preintervention survey data regarding care and communication provided by internal medicine residents and medical subspecialty fellows. We examined associations between patient and family race or socioeconomic status and ratings they gave trainees on two questionnaires: the Quality of End-of-Life Care (QEOLC) and Quality of Communication (QOC).

RESULTS

Patients from racial/ethnic minority groups, patients with lower income, and patients with lower educational attainment gave trainees higher ratings on the end-of-life care subscale of the QOC (QOCeol). In path models, patient educational attainment and income had a direct effect on outcomes, while race/ethnicity did not. Lower family educational attainment was also associated with higher trainee ratings on the QOCeol, while family non-white race was associated with lower trainee ratings on the QEOLC and general subscale of the QOC.

CONCLUSIONS

Patient race is associated with perceptions of the quality of communication about end-of-life care provided by physicians-in-training, but the association was opposite to our hypothesis and appears to be mediated by socioeconomic status. Family member predictors of these perceptions differ from those observed for patients. Further investigation of these associations may guide interventions to improve care delivered to patients and families.

Palliative Care Awareness among Indian Undergraduate Health Care Students: A Needs-Assessment Study to Determine Incorporation of Palliative Care Education in Undergraduate Medical, Nursing and Allied Health Education

Purpose:

Quality assurance data worldwide suggests that the current healthcare system is providing inadequate care for the dying. Current health care education focuses entirely on cure and care is almost compromised or nonexistent in end-of-life settings. The purpose of this study was to determine palliative care awareness among Indian undergraduate health care students and assess the need for incorporating palliative medicine education into undergraduate health education.

Materials and Methods:

A non-randomized population based study was conducted using 39-point questionnaire. Undergraduate medical, nursing and allied health students of Manipal University were the target population.

Results:

326 students participated in the study. 61.7% of students feel that resuscitation is appropriate in advanced metastatic cancer. 67.5% feel that all dying patients need palliative care and most of the students think that palliative care is equivalent to pain medicine, geriatric medicine and rehabilitation medicine. 89% of students think that Morphine causes addiction in palliative care setting. 60.7% of students feel that prognosis should only be communicated to the family.

Conclusion:

The outcomes of the study showed that the basic knowledge of palliative care among students was inadequate, and students are unprepared and uncertain in their approach of delivering end-of-life care.

Effects of educational intervention on nurses' knowledge, attitudes, and behavioral intentions toward supplying artificial nutrition and hydration to terminal cancer patients

INTRODUCTION

This study aimed to investigate the effects of educational intervention on nurses' knowledge, attitudes, and behavioral intentions regarding supplying artificial nutrition and hydration (ANH) to terminal cancer patients.

MATERIALS AND METHODS

A quasi-experimental design was adopted. A structured questionnaire evaluated the effects of educational intervention. From April to June 2005, 88 nurses were enrolled in the gastroenterology, general surgery, and intensive care unit of Taipei Veterans General Hospital in Taiwan. The nurses were randomly assigned into experimental and control groups in equal numbers (44 nurses in each group). After the experimental and control groups completed the pretest, the experimental group participated in a 50-min lecture. Both groups received a post-test 2 weeks after the lecture.

RESULTS

This study showed that prior to educational intervention, nurses have possessed experiences of ANH use in routine caring for terminal cancer patients. However, due to the lack of knowledge about supplying ANH to terminal cancer patients, the nurses trended toward the negative behavioral intention, although they realized the burdens of ANH in these patients. After educational intervention, mean scores of knowledge, attitudes and behavioral intentions of the experimental group increased significantly (z = -5.255, p < 0.001; t = -5.191, p < 0.001; z = -3.274, p <== 0.001). Mean score changes of knowledge and attitude between these two groups reached significant differences (t = -7.306, p < 0.001; t = -4.165, p < 0.001), but no significant difference was observed in the mean score change of behavioral intention (z = -1.943, p > 0.05).

CONCLUSION

The educational intervention remarkably improved nurses' knowledge and attitudes regarding supplying terminal cancer patients with ANH. As for the changes in the behavioral intentions, it requires long-term moral and ethical training and communication. The results of this research emphasized the importance of educational interventions, which should be considered seriously in future reference nursing education program.

Outcomes from a national multispecialty palliative care curriculum development project

BACKGROUND

In 1998 we completed a successful regional pilot project in palliative care curriculum development among 32 internal medicine residency programs recruited from the mid-western United States. Between 1999 and 2004 this project was expanded to include 358 U.S. programs, from four specialties, based on new training requirements in internal medicine, family medicine, neurology, and general surgery.

OBJECTIVE

To assess the 1-year outcomes from residency programs participating in a national multispecialty palliative care curriculum development project.

MEASUREMENT

Outcome data obtained from residency programs' responses to a structured progress report 12 months after enrolling in the project and from published residency project reports.

RESULTS

Three hundred fifty-eight residency programs, representing 27% of all eligible training programs in the four specialties, participated in the project. Outcome data was available from 224 residencies (63%). Most programs started new teaching in pain, non-pain symptom management, and communication skills. More than 50% of programs integrated palliative care topics within established institutional grand rounds, morbidity/mortality conferences or morning report. More than 70% of internal medicine and family practice programs began new direct patient care training opportunities utilizing hospital-based palliative care or hospice programs. New faculty development initiatives and use of quality improvement projects to drive curriculum change were reported in less than 50% of programs.

CONCLUSIONS

Focused short-term instruction in palliative care curriculum development, in a diverse group of residency programs, is feasible and associated with significant curriculum change.

Medical residents' perspectives on discussions of advanced directives: can prior experience affect how they approach patients?

INTRODUCTION

Resident physicians are inadequately taught how to communicate with patients about end-of-life decision making. Their beliefs about resuscitation and prior experiences with end-of-life care may impact the manner in which they approach patients.

OBJECTIVE

To explore residents' perceptions of end-of-life discussions, determine the features they find most important, and discern the challenges they face in this process.

METHODS

Internal medicine residents were surveyed about their experiences discussing resuscitation with patients including perceptions of patient understanding, outcomes of resuscitation, and regret about attempting to resuscitate patients. They were asked what features of these discussions are most important and which are the most challenging. Qualitative content analysis was used to examine the responses to open-ended questions.

RESULTS

Fifty-five residents completed the survey. Residents reported rarely feeling satisfied with the results of these discussions and disagreed with the decision for resuscitation numerous times. They perceive that few patients and families understand resuscitation. In their description of important features, they focus on the content of the discussion rather than the process, with the most common responses centering on a description of resuscitation. In contrast, the greatest challenge they identify is dealing with the emotional aspects of the discussion.

CONCLUSIONS

Residents report internal conflict about their experiences discussing resuscitation with patients. Their approach to these discussions focuses on resuscitation itself with less attention paid to processes that might improve patient decision making. The challenges they describe may be overcome with improved education about end-of-life communication.

Learning to provide end-of-life care: postgraduate medical training programs in Michigan

PURPOSE

A statewide survey of postgraduate medical training programs was conducted to determine the current status of training related to end-of-life (EOL) care and hospice care training.

METHODS

A mail survey of 275 program directors was conducted with a response rate of 70%. The questionnaire focused on information about training in EOL care and hospice care: specific content, required and elective experiences, teaching formats, and program directors' ratings of the perceived adequacy of training. This study received Institutional Review Board (IRB) approval.

RESULTS

Less than half (46%) of the residency programs reported any formal training in EOL care, and less than one third (31%) reported training in hospice care. A majority of programs with EOL and/or hospice training required it for all residents. Of the programs with required hospice training, only half included a clinical component; fewer programs with EOL training reported a clinical component. Most program directors rated their programs as adequate or excellent in terms of EOL and hospice care, whether they had formal training or not.

CONCLUSIONS

The results of the survey demonstrate considerable variability in training with respect to hospice and EOL care. Training through direct clinical experience was infrequently reported. There has been little formal adoption of published curricula in this area. The high level of adequacy in the rating of training by program directors contrasts with relative lack of reported curriculum content and implementation, suggesting that improvements in EOL care training will be slow to come if left in the hands of program directors.

Detecting attitudinal changes about death and dying as a result of end-of-life care curricula for medical undergraduates

BACKGROUND

There is heightened emphasis on teaching end-of-life (EOL) care in the medical school curriculum, but a relative paucity of tools focused on assessing key attitudinal changes due to curricula.

OBJECTIVE

We sought to evaluate the responsiveness of two validated measures of relevant attitudes to changes caused by two EOL curricula: a year-long Elective and a day-long Inter-Clerkship for medical undergraduates.

DESIGN

A case control design (n = 100) and a one group pretest-posttest design (n = 98) were used to ask: (1) Are these two attitudinal measures responsive to changes induced by two undergraduate EOL curricula? (2) Do these two curricula have an additive effect (i.e., taking both yields a stronger attitudinal change than taking only one)? (3) Are there attitudinal and sociodemographic differences between students who took the year-long elective EOL course and those who did not?

SUBJECTS

Undergraduate medical students.

MEASUREMENTS

Two self-report measures: Concept of a Good Death and Concerns about Dying.

RESULTS

Compared to nonelective participants, Elective participants reported less concern about working with dying patients at the end of the course and increased their valuation of clinical criteria in thinking about a "good death." There were trends suggesting decreased general concern about dying and increased valuation of closure, and an interaction suggesting a larger impact on those with higher precourse concern scores. There were no differences between elective and nonelective participants at baseline. The Interclerkship increased students' valuation of personal control aspects of death, and there was a trend in reducing concerns about working with dying patients. We did not find an additive effect of taking both curricula.

CONCLUSIONS

We conclude that both measures were responsive to the relatively large effects this study would have been able to detect, and may be useful in future research to substantiate the effectiveness of EOL curricula in influencing attitudes and level of comfort with death and dying.

Palliative care in advanced dementia: a randomized controlled trial and descriptive analysis

BACKGROUND

Few patients with end-stage dementia are enrolled in hospice care. A palliative care approach would nonetheless seem to be appropriate in various care settings, including the acute care hospital.

METHODS

We conducted a randomized controlled trial of palliative care in patients with advanced dementia (Functional Assessment Staging Tool [FAST] stage 6d-7f) who were hospitalized with acute illness. Intervention patients received recommendations by a palliative care team with the goal of enhancing patient comfort; control patients received usual care without these recommendations.

RESULTS

Among 99 patients enrolled over 3 years, groups were comparable at baseline in terms of gender, age, race, dementia stage, and advance directive status. Outcomes were similar in terms of mean number of hospitalizations, average length of stay, and mortality. Intervention patients were more likely than control patients to receive a palliative care plan (23% versus 4%; p = 0.008), usually on discharge, and more decisions were made to forgo certain medical treatments but the numbers were small. Fewer patients in the intervention group received intravenous therapy throughout the admission (66% vs. 81%, p = 0.025). Overall, additional interventions included daily phlebotomy for at least half of the admission (41%), systemic antibiotics (75%), and new feeding tubes (44%). Including tubes present at the time of randomization, a total of 69% received long-term enteral feeding.

CONCLUSION

It was difficult for a palliative care research team to influence the care of advanced dementia patients in the acute hospital setting. When patients have advanced dementia, there may be unique barriers, including perceived prognostic uncertainty, difficulty assessing comfort level, and perceptions about tube feeding. There must be a reexamination of treatment approaches for this severely impaired group of patients. Further study should attempt to identify patients prior to the need for acute hospitalization so goals can be established when there is less urgency to make life and death decisions.

A faculty development course for end-of-life care

A faculty development course was offered at the Medical College of Wisconsin to bolster existing medical student and housestaff training opportunities in palliative medicine. An 8- week, 12 contact-hour course was designed to provide up to 15 faculty members training in the practice and teaching of end-of-life care. Fifteen faculty registered, but only 10 attended at least three of eight educational sessions. Educational formats included didactic presentations, case studies, study guides and completion of action plans-explicit plans for utilization of newly learned material in clinical and educational practice. In a retrospective, pre/post self-evaluation, participants indicated poor or fair precourse knowledge and self-confidence in most areas of end-of-life care. Significant improvement in end-of-life knowledge and selfconfidence was noted for eight of 11 content areas and in self-assessed education skills in six of seven content areas. Although attendance was disappointing, the course was strongly endorsed by participating faculty. Faculty who attended at least three sessions reported significant improvement in many aspects of end-of-life clinical care, as well as in self-confidence and education skills, and were able to use the educational material to train a range of learners. Sample educational material is included with this report.

Assessing Competence of Residents to Discuss End-of-Life Issues

BACKGROUND

Residents are often responsible for eliciting patients' treatment preferences at the end of life (EOL), yet we have a limited understanding of their competence in this task.

OBJECTIVE

To assess the competence of medical residents to discuss advance directives (AD) with patients using two measures: self-assessment (perceived competence) and self-reported behaviors (behavioral competence). To examine the relationship between educational experiences and these two measures of competence.

DESIGN

Cross-sectional self-report questionnaire.

SUBJECTS

Internal medicine residents from two university- and one community-based program.

RESULTS

The 282 respondents (84% response) had an average of 6.2 EOL discussions per month. Few residents reported having received useful feedback from a resident (8%) or an attending (7%) about their ability to discuss ADs. Even fewer reported that work rounds (4%) or attending rounds (5%) were frequently forums for learning about EOL care. Mean perceived competence was 3.8 (range, 1-5). In multivariable analyses, greater perceived competence was significantly associated with higher postgraduate year (p < 0.001), having residents demonstrate exemplary AD discussions (p < 0.001), and less formal education (p < 0.01). Behavioral competence was significantly associated with reporting that work rounds were useful for learning about EOL care (p = 0.002), less formal education (p = 0.02) and a greater number of EOL discussions per ward month (p = 0.009). The correlation between perceived and behavioral competence (r = 0.25, p = 0.001) was modest but statistically significant.

CONCLUSIONS

Many residents view themselves as competent to discuss ADs with patients but fail to engage in recommended behaviors for such discussions. Increasing experiential learning may be the most promising means of enhancing residents' abilities to discuss EOL issues with patients.

An Undergraduate Course on Palliative Medicine and End-of-Life Issues

BACKGROUND

The concept and development of this course were the joint efforts of the directors of the Susquehanna University Office of the Chaplain and the Geisinger Health System Palliative and Supportive Medicine Program (PMP). Both individuals perceived a need for increased awareness of students for issues related to advancing age and terminal illness.

OBJECTIVES

Our objectives in formulating and presenting this course were to demystify aging, illness and death; increase awareness and tolerance for cultural and religious differences; enhance empathy and teach compassion; provide communication skills that could be used in many difficult situations; and provide a caring and mutually beneficial relationship for the elderly and students in our community.

DESIGN

The one semester course consisted of 28 one-hour forty-five minute classes and a separate service-learning project. One half of the lectures, presented by the Susquehanna University chaplain (M.R.), predominantly involved religious and spiritual issues. The other 14 were organized by the PMP and were presented primarily by health care professionals. A required service-learning project was the creation of a "personal legacy."

SETTINGS/SUBJECTS

The PMP group comprised 7 physicians, 3 nurses, 1 chaplain, and 2 individuals participating in volunteer community activities for the elderly and infirm. All volunteered their time for this endeavor. Each had autonomy concerning his class content and format. Eighteen students (2 seniors, 6 juniors, 7 sophomores and 3 freshmen) registered for and completed the course.

MEASUREMENTS

In the final week, students were asked to evaluate the course with predominantly open-ended questions. They were informed that they would not be graded on their responses, and complete candor was encouraged. A less detailed evaluation of the overall experience by the course instructors was also solicited. These various comments are reviewed and discussed.

RESULTS AND CONCLUSIONS

Overall, student and faculty comments about the course were quite positive. Every student believed that it was a very worthwhile course, but 4 of 18 would not sign up for it again and would not recommend it to a friend. We used the comments from the student and faculty participants to change the curriculum and presentation style for future courses.

Palliative Care Education Integrated into a Geriatrics Rotation for Resident Physicians

The authors present the curricular elements of a palliative care experience for internal medicine residents at the Medical College of Wisconsin (MCW) and the Zablocki Veterans Affairs Medical Center (ZVAMC), Milwaukee, Wisconsin. To improve resident physicians' knowledge and skills in palliative care, a structured clinical/educational experience was integrated into an existing required geriatrics rotation for senior medicine residents. Each month, two residents rotate simultaneously in the palliative care and the geriatrics evaluation and management units at the ZVAMC. The curricular elements of palliative care include prognostication, assessment and management of pain and nonpain symptoms in end-of-life care. The geriatrics component emphasizes mechanisms of aging, pathophysiology of common geriatric diseases, clinical pharmacology and psychosocial aspects of geriatric care. Teaching methods include direct patient care, bedside teaching rounds, lectures, and multidisciplinary and family meetings. Rotation design avoided conflicting time demands on the residents. In a prerotation/postrotation knowledge self-assessment questionnaire, residents (n = 28) indicated significant knowledge improvement in all palliative care domains taught during the experience. The rotation was well integrated into the existing curricular elements in geriatrics and palliative medicine at MCW. This combined rotation can serve as a reference for educators interested in developing new or enhancing existing palliative care training programs.

Interns Learning to Care for Dying Patients

OBJECTIVE

To examine interns' perceptions of the emotional support they were able to provide to dying patients and their families, as well as their evaluation of attending physicians as role models caring for dying patients and their families.

METHODS

A semistructured, face-to-face interview of a convenience sample of 38 internal medicine interns in two New York City teaching hospitals who were the primary house officers of patients dying between January 2000 and April 2000.

RESULTS

Fifty-eight percent of interns rated their comfort level in talking to their patient and family about end-of-life issues as good to excellent. Sixty percent of interns estimated that their impact on their patient's emotional experiences as they approached death as none to minimal. Seventy-four percent of interns rated their patient's physical comfort level good to excellent. Interns rated attending physicians as effective role models in 66% of cases; 34% percent were rated as poor to mediocre. Observation of attending physicians with patients and families was rated as the most effective method to learn how to care for dying patients.

CONCLUSIONS

While most interns felt comfortable speaking to their patients and their families about end-of-life issues, they also believed that they provided only minimal emotional support. Interns believe that direct observation of attending physicians is the most effective way to improve their skills caring for dying patients and their families; however, they report wide variability in attending physician performance as role models.

A Palliative Care Needs Assessment of Health Care Institutions in Wisconsin

BACKGROUND

In 1999 the Wisconsin Coalition to Improve Palliative Care (WCIPC) conducted a palliative care needs assessment of health care institutions throughout the state of Wisconsin to document the current status of palliative care and identify institutional barriers and opportunities for improvement.

METHOD

A survey instrument was developed to assess provisions of palliative care in the following areas: services currently provided, staff education programs offered in the previous year, barriers to the delivery of palliative care, and resources that would be useful to the participating institutions. Surveys were mailed to 881 health care institutions in Wisconsin; 318 (36%) surveys were returned.

RESULTS

The three most common end-of-life care services present included a program to promote advance care planning, a contractual relationship with one or more hospice programs, and an interdisciplinary care program for dying patients. Pain management and advance directives were the two most common topics of educational programs offered in the past year. The most frequently cited barriers to good end-of-life care included a lack of knowledge among patients/families, a lack of provider knowledge about pain and symptom control, and poor reimbursement for end-of-life care. Resources that institutions felt would be useful included newsletters, a speaker's bureau, and information about establishing quality improvement programs for palliative care.

CONCLUSIONS

While health care institutions in Wisconsin provide a variety of palliative care services and offer educational programs that address areas of palliative care, institutional barriers do exist. This needs assessment provides valuable descriptive data that will guide efforts to improve palliative care throughout the state of Wisconsin.

An Integrated Biopsychosocial Approach to Palliative Care Training of Medical Students

In 1996 the University of Rochester School of Medicine, Rochester, New York, began a major curricular reform called the Double Helix Curriculum, integrating basic science and clinical training over 4 years of medical school. This transition provided a unique opportunity to develop and implement a fully integrated, comprehensive palliative care curriculum. In this three-part paper, we will describe: (1) our process of finding curricular time, setting priorities, and deciding on pedagogical strategies; (2) an overview of how palliative care teaching was integrated into the general curriculum, including examples of different teaching opportunities; and (3) our evaluation process, and some ongoing challenges. Because palliative care is a core element in the care of all seriously ill patients, we chose to integrate our teaching into multiple courses over 4 years of undergraduate medical education, and not isolate it in a particular course. We view this report not as an ideal curriculum to be emulated in its entirety but as a work in progress that may be somewhat unique to our institution. We intend to illustrate a process of incremental curriculum building, and to generate some fresh teaching ideas from which palliative care educators can select depending on their own curricular needs and objectives.

Can a pain management and palliative care curriculum improve the opioid prescribing practices of medical residents?

BACKGROUND

Although opioids are central to acute pain management, numerous studies have shown that many physicians prescribe them incorrectly, resulting in inadequate pain management and side effects. We assessed whether a case-based palliative medicine curriculum could improve medical house staff opioid prescribing practices.

DESIGN

Prospective chart review of consecutive pharmacy and billing records of patients who received an opioid during hospitalization before and after the implementation of a curricular intervention, consisting of 10 one-hour case-based modules, including 2 pain management seminars.

MEASUREMENTS

Consecutive pharmacy and billing records of patients who were cared for by medical residents (n = 733) and a comparison group of neurology and rehabilitative medicine patients (n = 273) that received an opioid during hospitalization in 8-month periods before (1/1/97 to 4/30/97) and after (1/1/99 to 4/30/99) the implementation of the curriculum on the medical service were reviewed. Three outcomes were measured: 1) percent of opioid orders for meperidine; 2) percent of opioid orders with concomminant bowel regimen; and 3) percent of opioid orders using adjuvant nonsteroidal anti-inflammatory drugs (NSAIDs).

MAIN RESULTS

The percentage of patients receiving meperidine decreased in the study group, but not in the comparison group. The percentages receiving NSAIDs and bowel medications increased in both groups. In multivariate logistic models controlling for age and race, the odds of an experimental group patient receiving meperidine in the post-period decreased to 0.55 (95% confidence interval [95% CI], 0.32 to 0.96), while the odds of receiving a bowel medication or NSAID increased to 1.48 (95% CI, 1.07 to 2.03) and 1.53 (95% CI, 1.01 to 2.32), respectively. In the comparison group models, the odds of receiving a NSAID in the post-period increased significantly to 2.27 (95% CI, 1.10 to 4.67), but the odds of receiving a bowel medication (0.45; 95% CI, 0.74 to 2.00) or meperidine (0.85; 95% CI, 0.51 to 2.30) were not significantly different from baseline.

CONCLUSIONS

This palliative care curriculum was associated with a sustained (>6 months) improvement in medical residents' opioid prescribing practices. Further research is needed to understand the changes that occurred and how they can be translated into improved patient outcomes.

Senior medical students' perceptions of the adequacy of education on end-of-life issues

CONTEXT

It is unclear how well prepared U.S. senior medical students are to handle end-of-life issues as they reach the end of medical school. Additionally, the most optimal way of providing medical student end-of-life education has not been adequately defined.

OBJECTIVE

This study aims to determine the preparedness of senior medical students at U.S. medical schools regarding end-of-life issues.

DESIGN

A self-administered survey.

SETTING

Six medical schools throughout the United States, two of which have a formal curriculum on end-of-life issues, and four of which do not.

PARTICIPANTS

Fourth-year medical students during November through February of their senior year.

MAIN OUTCOME MEASURE

Self-reported preparation on a number of end-of-life competencies.

RESULTS

Of the 757 surveys sent out, 262 responses were received (34.6%). Only 22% to 53% of students (varying by topic) felt prepared by their education in the selected end-of-life competencies. Students attending medical schools with a formal end-of-life curriculum were more likely to feel prepared than students with no formal curriculum to address psychosocial issues (21% higher, p = 0.008), cultural/spiritual issues (21% higher, p = 0.005), technical aspects of end-of-life care (18% higher, p = 0.001), and treatment of common symptoms (34% higher, p = 0.001). Students who had more clinical experiences in palliative care were more likely to feel prepared to discuss end-of-life issues with patients (p = 0.013) and to treat common symptoms (p = 0.011).

CONCLUSIONS

This study demonstrates support for development of formal curriculum on end-of-life issues, and emphasizes the importance of clinical exposure to terminally ill patients to prepare medical students to provide quality end-of-life care.

Analyzing end-of-life care legislation: a social work perspective

Several policy approaches are currently being considered in an attempt to organize a national response to the crisis surrounding quality end-of-life care. Recent healthcare efforts aimed at supporting individuals facing advanced illness are marked by debate over assisted suicide, untimely referrals to hospice care, inconsistent adherence to advance directives, and substantive amounts of unrelieved pain in end-of-life. Social workers require a clear understanding of the current political and social climate if they are to navigate the ethical dilemmas as they are presented in end-of-life care. This article discusses recently proposed policy responses to the various political and social controversies surrounding end-of-life care for individuals facing advanced illness. The analysis will suggest criteria for evaluating end-of-life policy in general and offer a framework for evaluating proposed legislation. Suggestions for making end-of-life policy more effective and areas for future research will be proposed. Finally, the implications of this policy analysis for social work will be delineated.

C.A.R.E.: an approach for teaching ethics in medicine

Various societal factors have contributed to an increase in the ethical dilemmas faced by physicians, yet limited formal training in ethical decision-making is provided for those practitioners during their medical education. The pluralistic nature of contemporary medicine seems amenable to the development of common clinical and educational approaches to ethical dilemmas. The authors propose one such framework--a four question approach called C.A.R.E.--that encourages physicians at all levels of training to acknowledge individual and collective factors that enter into ethical decision-making. These questions are clearly described, and examples for use of the model in teaching settings are also provided. The authors believe that this approach can have significant utility in medical education and clinical settings, and advocate for its use and evaluation.

Goals and Strategies for Teaching Death and Dying in Medical Schools

Teaching medical students to respond to needs of the dying represents an important challenge for medical educators. This article describes the goals and objectives that should be identified before medical schools can meet this challenge, as well as strategies that, when implemented, will provide students with the necessary knowledge, skills, and attitudes to meet the needs of the dying patients. The goals and objectives were identified through a modified group consensus process developed during Choice In Dying's 5-year project "Integrating Education on Care of the Dying into Medical Schools." The authors have diverse experiences and backgrounds and are actively involved in death and dying teaching at 11 medical schools. They conclude that after accepting the goals and objectives, key medical school faculty can work cooperatively to develop strategies to integrate them into the school's curriculum. Without first establishing a set of goals and objectives and developing evaluation methods, medical schools could miss their mark in fostering the student's ability to care for the dying.