Incorporating palliative care into primary care education. National Consensus Conference on Medical Education for Care Near the End of Life

Building an action plan to tackle palliative care inequality through multi-stakeholder platforms

Background

To achieve universal care and overcome existing barriers, the most effective strategy is to devise an action plan that incorporates palliative care into primary health care (PHC), as recommended by the World Health Organization's (WHO) Astana Declaration. In Colombia, a country with an upper-middle-income status, about 128,000 individuals experience severe health-related suffering (SHS) that necessitates palliative care. Although the country's healthcare system has made steady strides in the integration and development of palliative care, there is still no national plan in place for palliative care.

Objective

Build up Colombia's palliative care plan through stakeholder consensus.

Method

Based on the participatory action research method and the multi-stakeholder platforms model, this study convened 142 stakeholders from different levels of the health system (patient representatives, journalists, health professionals, government entities, insurance companies, universities, and drug regulatory authorities).

Results

The national plan aims to achieve its objectives through a series of strategic actions. These include integrating and diversifying palliative care services, improving access to opioids, increasing palliative care education, promoting community-based palliative care programs, securing funding, and implementing a regulatory framework for palliative care by public policymakers.

Conclusions

The national palliative care is an alliance that aims to reduce palliative care inequity in Colombia by 2026 by empowering stakeholders nationwide to collaborate around specific goals and objectives.

Finding their place - general practitioners' experiences with palliative care-a Norwegian qualitative study

BACKGROUND

Modern palliative care focuses on enabling patients to spend their remaining time at home, and dying comfortably at home, for those patients who want it. Compared to many European countries, few die at home in Norway. General practitioners' (GPs') involvement in palliative care may increase patients' time at home and achievements of home death. Norwegian GPs are perceived as missing in this work. The aim of this study is to explore GPs' experiences in palliative care regarding their involvement in this work, how they define their role, and what they think they realistically can contribute towards palliative patients.

METHODS

We performed focus group interviews with GPs, following a semi-structured interview guide. We included four focus groups with a total of 25 GPs. Interviews were recorded and transcribed verbatim. We performed qualitative analysis on these interviews, inspired by interpretative phenomenological analysis.

RESULTS

Strengths of the GP in the provision of palliative care consisted of characteristics of general practice and skills they relied on, such as general medical knowledge, being coordinator of care, and having a personal and longitudinal knowledge of the patient and a family perspective. They generally had positive attitudes but differing views about their formal role, which was described along three positions towards palliative care: the highly involved, the weakly involved, and the uninvolved GP.

CONCLUSION

GPs have evident strengths that could be important in the provision of palliative care. They rely on general medical knowledge and need specialist support. They had no consensus about their role in palliative care. Multiple factors interact in complex ways to determine how the GPs perceive their role and how involved they are in palliative care. GPs may possess skills and knowledge complementary to the specialized skills of palliative care team physicians. Specialized teams with extensive outreach activities should be aware of the potential they have for both enabling and deskilling GPs.

Process of Developing Palliative Care Curriculum for Training Medical Interns in a Tertiary Care Teaching Hospital in Puducherry, India

Objectives

The department of community medicine (DCM) has been training medical interns for palliative care in the hospital and community setting. There was no specific curriculum or course material available for training them. This study aims to develop, implement and evaluate the palliative care curriculum for training medical interns.

Materials and Methods

The present program development and evaluation of palliative care curriculum was done in the DCM, Sri Manakula Vinayagar Medical College and Hospital, Puducherry, India. We followed the Kern's six steps for curriculum development. It was done during July 2016 and May 2017. We framed expected outcomes from literature review and interviews with experts. The curriculum was delivered through small group sessions followed by hands-on exposure to hospital- and community-based palliative care programs guided by a workbook. Medical interns were given feedback on their field assignments on history taking, followed by reflection using structured template incorporated in the workbook. The reaction to the curriculum was collected from various stakeholders.

Results

Medical interns found the curriculum useful for them to acquire basic skills of pain management, communication skills and teamwork. Patients and family felt satisfied with the quality of care provided.

Conclusion

The new palliative care curriculum was well received by all the stakeholders involved. This can be adopted in similar context for training medical interns in palliative care.

Building capacity for palliative care delivery in primary care settings: Mixed-methods evaluation of the INTEGRATE Project

OBJECTIVE

To evaluate an intervention aimed at building capacity to deliver palliative care in primary care settings.

DESIGN

The INTEGRATE Project was a 3-year pilot project involving interprofessional palliative care education and an integrated care model to promote early identification and support of patients with palliative care needs. A concurrent mixed-methods evaluation was conducted using descriptive data, provider surveys before and after implementation, and interviews with providers and managers.

SETTING

Four primary care practices in Ontario.

PARTICIPANTS

All providers in each practice were invited to participate. Providers used the "surprise question" as a prompt to determine patient eligibility for inclusion.

MAIN OUTCOME MEASURES

Provider attitudes toward and confidence in providing palliative care, use of palliative care tools, delivery of palliative care, and perceived barriers to delivering palliative care.

RESULTS

A total of 294 patients were identified for early initiation of palliative care, most of whom had multiple comorbid conditions. Results demonstrated improvement in provider confidence to deliver palliative care (30% mean increase, P < .05) and self-reported use of palliative care tools and services (25% mean increase, P < .05). There was substantial variation across practices regarding the percentage of patients identified using the surprise question (0.2% to 1.5%), the number of advance care planning conversations initiated (50% to 90%), and mean time to conversation (13 to 76 days). This variation is attributable, in part, to contextual differences across practices.

CONCLUSION

A standardized model for the early introduction of palliative care to patients can be integrated into the routine practice of primary care practitioners with appropriate training and support. Additional research is needed to understand the practice factors that contribute to the success of palliative care interventions in primary care and to examine patient outcomes.

Health Personnel's Knowledge, Attitudes, and Self-Efficacy Related to Providing Palliative Care in Persons with Chronic Diseases

Purpose

The purpose of this study was to examine the relationships of knowledge, attitudes, and self-efficacy related to palliative care among health care providers (doctors and nurses) in order to provide a basis to develop a training program for health care providers.

Methods

A correlational and descriptive study design was used. Participants were recruited from a university-affiliated hospital located in Daejeon and an e-nurse community. After IRB approval, data were collected from July 12, 2018, to September 30, 2018. A total of 169 responses were finally analyzed using version SPSS 24. The data were analyzed in terms of descriptive statistics (frequency and percentage or mean and standard deviation, as appropriate), the t-test, analysis of variance (with the Duncan post hoc test), and Pearson correlation coefficients.

Results

Knowledge, attitudes, and self-efficacy were significantly higher in those who had received palliative care training or had been exposed to awareness-raising initiatives. There were positive relationships among knowledge, attitudes, and self-efficacy, with small to moderate effect sizes.

Conclusion

Palliative care training for health care professionals is necessary to meet patients' needs. Such programs should take into account not only knowledge about palliative care, but also ways to improve empathy and resolve ethical dilemmas. Interprofessional training would be an excellent option to share therapeutic goals and develop communication skills among multidisciplinary team members.

Patient Risk Factor Profiles Associated With the Timing of Goals-of-Care Consultation Before Death: A Classification and Regression Tree Analysis

Background:

Early palliative care consultation (“PCC”) to discuss goals-of-care benefits seriously ill patients. Risk factor profiles associated with the timing of conversations in hospitals, where late conversations most likely occur, are needed.

Objective:

To identify risk factor patient profiles associated with PCC timing before death.

Methods:

Secondary analysis of an observational study was conducted at an urban, academic medical center. Patients aged 18 years and older admitted to the medical center, who had PCC, and died July 1, 2014 to October 31, 2016, were included. Patients admitted for childbirth or rehabilitationand patients whose date of death was unknown were excluded. Classification and Regression Tree modeling was employed using demographic and clinical variables.

Results:

Of 1141 patients, 54% had PCC “close to death” (0-14 days before death); 26% had PCC 15 to 60 days before death; 21% had PCC >60 days before death (median 13 days before death). Variables associated with receiving PCC close to death included being Hispanic or “Other” race/ethnicity intensive care patients with extreme illness severity (85%), with age <46 or >75 increasing this probability (98%). Intensive care patients with extreme illness severity were also likely to receive PCC close to death (64%) as were 50% of intensive care patients with less than extreme illness severity.

Conclusions:

A majority of patients received PCC close to death. A complex set of variable interactions were associated with PCC timing. A systematic process for engaging patients with PCC earlier in the care continuum, and in intensive care regardless of illness severity, is needed.

Australian GPs' perceptions of barriers and enablers to best practice palliative care: a qualitative study

Background

General Practitioners (GPs) often play an important role in caring for people at the end of life. While some international studies suggest that GPs experience a number of barriers to providing palliative care, little is known about views and experiences of GPs in Australia. This study explored Australian GPs’ perceptions of barriers and enablers to the provision of palliative care and provides new insights into how to implement best practice care at the end of life.

Methods

This was a qualitative study using 25 semi-structured phone interviews conducted with GPs practising in metropolitan and non-metropolitan New South Wales, Australia. Data were analysed using qualitative content analysis.

Results

GPs reported difficulties with palliative care provision due to i) the complex and often emotional nature of doctor-family-interaction; ii) a lack of evidence to guide care; and iii) the need to negotiate roles and responsibilities within the healthcare team. GPs listed a number of strategies to help deal with their workload and to improve communication processes between healthcare providers. These included appropriate scheduling of appointments, locally tailored mentoring and further education, and palliative care guidelines which more clearly outline the roles and responsibilities within multidisciplinary teams. GPs also noted the importance of online platforms to facilitate their communication with patients, their families and other healthcare providers, and to provide centralised access to locally tailored information on palliative care services. GPs suggested that non-government organisations could play an important role by raising awareness of the key role of GPs in palliative care provision and implementing an “official visitor” program, i.e. supporting volunteers to provide peer support or respite to people with palliative care needs and their families.

Conclusions

This study offers new insights into strategies to overcome well documented barriers to palliative care provision in general practice and help implement optimal care at the end of life. The results suggest that researchers and policy makers should adopt a comprehensive approach to improving the provision of palliative care which tackles the array of barriers and enablers identified in this study.

Prioritizing Primary Care Patients for a Communication Intervention Using the "Surprise Question": a Prospective Cohort Study

BACKGROUND

Communication about priorities and goals improves the value of care for patients with serious illnesses. Resource constraints necessitate targeting interventions to patients who need them most.

OBJECTIVE

To evaluate the effectiveness of a clinician screening tool to identify patients for a communication intervention.

DESIGN

Prospective cohort study.

SETTING

Primary care clinics in Boston, MA.

PARTICIPANTS

Primary care physicians (PCPs) and nurse care coordinators (RNCCs) identified patients at high risk of dying by answering the Surprise Question (SQ): "Would you be surprised if this patient died in the next 2 years?"

MEASUREMENTS

Performance of the SQ for predicting mortality, measured by the area under receiver operating curve (AUC), sensitivity, specificity, and likelihood ratios.

RESULTS

Sensitivity of PCP response to the SQ at 2 years was 79.4% and specificity 68.6%; for RNCCs, sensitivity was 52.6% and specificity 80.6%. In univariate regression, the odds of 2-year mortality for patients identified as high risk by PCPs were 8.4 times higher than those predicted to be at low risk (95% CI 5.7-12.4, AUC 0.74) and 4.6 for RNCCs (3.4-6.2, AUC 0.67). In multivariate analysis, both PCP and RNCC prediction of high risk of death remained associated with the odds of 2-year mortality.

LIMITATIONS

This study was conducted in the context of a high-risk care management program, including an initial screening process and training, both of which affect the generalizability of the results.

CONCLUSION

When used in combination with a high-risk algorithm, the 2-year version of the SQ captured the majority of patients who died, demonstrating better than expected performance as a screening tool for a serious illness communication intervention in a heterogeneous primary care population.

A Needs Assessment for Southern Manitoba Physicians for Palliative Care Education

Recent calls for increased palliative care education of physicians and a need to improve the effectiveness of palliative care delivery in rural areas are the stimuli for this study. The needs assessment evaluated educational needs and preferences of physicians practicing in three Regional Health Authorities in southern Manitoba in 2000, as well as semi-structured interviews with health care workers in seven rural communities. Physicians report their knowledge of symptom management issues as adequate, although for other issues in palliative care such as bereavement, psychosocial aspects of dying, and professional issues, they have less confidence. Physicians prefer learning through case studies, lectures, and self-directed learning, in settings close to their community, on the weekend. Qualitative analysis from the semi-structured interviews revealed themes related to the role of physicians in rural palliative care: i) a need for physician education, ii) physician participation within the palliative care team, and iii) physician involvement in patient-centered care.

Joint position statement Indian Association of Palliative Care and Academy of Family Physicians of India - The way forward for developing community-based palliative care program throughout India: Policy, education, and service delivery considerations

Purpose:

This joint position statement, by the Indian Association of Palliative Care (IAPC) and Academy of Family Physicians of India (AFPI), proposes to address gaps in palliative care provision in the country by developing a community-based palliative care model that will empower primary care physicians to provide basic palliative care.

Evidence:

India ranks very poorly, 67th of 80 countries in the quality of death index. Two-thirds of patients who die need palliative care and many such patients spend the last hours of life in the Intensive care unit. The Indian National Health Policy (NHP) 2017 and other international bodies endorse palliative care as an essential health-care service component. NHP 2017 also recommends development of distance and continuing education options for general practitioners to upgrade their skills to provide timely interventions and avoid unnecessary referrals.

Methods:

A taskforce was formed with Indian and International expertise in palliative care and family medicine to develop this paper including an open conference at the IAPC conference 2017, agreement of a formal liaison between IAPC and AFPI and wide consultation leading to the development of this position paper aimed at supporting integration, networking, and joint working between palliative care specialists and generalists. The WHO model of taking a public health approach to palliative care was used as a framework for potential developments; policy support, education and training, service development, and availability of appropriate medicines.

Recommendations:

This taskforce recommends the following (1) Palliative care should be integrated into all levels of care including primary care with clear referral pathways, networking between palliative care specialist centers and family medicine physicians and generalists in community settings, to support education and clinical services. (2) Implement the recommendations of NHP 2017 to develop services and training programs for upskilling of primary care doctors in public and private sector. (3) Include palliative care as a mandatory component in the undergraduate (MBBS) and postgraduate curriculum of family physicians. (4) Improve access to necessary medications in urban and rural areas. (5) Provide relevant in-service training and support for palliative care to all levels of service providers including primary care and community staff. (6) Generate public awareness about palliative care and empower the community to identify those with chronic disease and provide support for those choosing to die at home.

Determining Palliative Care Penetration Rates in the Acute Care Setting

CONTEXT

Intermountain Healthcare, in collaboration with Cerner Corporation, developed a hospital-based electronic palliative care algorithm.

OBJECTIVES

This study aims to improve identification of patients who would benefit from palliative care services, and calculate palliative care penetration rates.

METHODS

This study used a mixed-methods nonrandomized retrospective study design. Three 30-day iterations of clinical data were analyzed for patients identified by the electronic algorithm. During the second and third 30-day iterations, palliative care clinicians conducted chart reviews on a weekly basis for identified patients and determined whether the patients were appropriate for a palliative care consult. Positive predictive values (PPVs) were calculated. Based on the PPV, palliative care consult penetration rates were also calculated.

RESULTS

During the first iteration, the algorithm triggered 2995 times on 1384 unique patient encounters (69.3% of the total inpatient population). In the second iteration, the algorithm triggered 851 times on 477 unique patient encounters (26.4% of the total inpatient population). Eight hundred twenty-one chart reviews were completed on 420 unique patient encounters. The PPV was 68.3%. Based on the PPV, the projected palliative care penetration rate was 17.6%. During the third iteration, the algorithm triggered 1229 times on 539 unique patient encounters (33.3% of the total inpatient population). Nine hundred sixty-seven chart reviews were completed on 505 unique patient encounters. The PPV was 80.1%. Based on the PPV, the projected palliative care penetration rate was 26.4%.

CONCLUSION

This study successfully optimized an electronic palliative care identification algorithm with a PPV of 80.1% and indicates appropriate palliative care penetration rates may be as high as 26.4% of the total inpatient population.

Validation of the German revised version of the program in palliative care education and practice questionnaire (PCEP-GR)

BACKGROUND

The evaluation of the effectiveness of undergraduate palliative care education (UPCE) programs is an essential foundation to providing high-quality UPCE programs. Therefore, the implementation of valid evaluation tools is indispensable. Until today, there has been no general consensus regarding concrete outcome parameters and their accurate measurement. The Program in Palliative Care Education and Practice Questionnaire (German Revised Version; PCEP-GR) is a promising assessment tool for UPCE. The aim of the current study was to evaluate the psychometric properties of PCEP-GR and to demonstrate its feasibility for the evaluation of UPCE programs.

METHODS

The practical feasibility of the PCEP-GR and its acceptance in medical students were investigated in a pilot study with 24 undergraduate medical students at Heinrich Heine University Dusseldorf, Germany. Subsequently, the PCEP-GR was surveyed in a representative sample (N = 680) of medical students in order to investigate its psychometric properties. Factorial validity was investigated by means of principal component analysis (PCA). Reliability was examined by means of split-half-reliability analysis and analysis of internal consistency. After taking into consideration the PCA and distribution analysis results, an evaluation instruction for the PCEP-GR was developed.

RESULTS

The PCEP-GR proved to be feasible and well-accepted in medical students. PCA revealed a four-factorial solution indicating four PCEP-GR subscales: preparation to provide palliative care, attitudes towards palliative care, self-estimation of competence in communication with dying patients and their relatives and self-estimation of knowledge and skills in palliative care. The PCEP-GR showed good split-half-reliability and acceptable to good internal consistency of subscales. Attitudes towards palliative care slightly missed the criterion of acceptable internal consistency. The evaluation instruction suggests a global PCEP-GR index and four subscales.

CONCLUSIONS

The PCEP-GR has proven to be a feasible, economic, valid and reliable tool for the assessment of UPCE that comprises self-efficacy expectation and relevant attitudes towards palliative care.

Evaluating an End-of-Life Curriculum in a Medical Residency Program

The ability to meet patient needs at the end of life is important. Boston University Residency Program in Medicine initiated a 1-week-long end-of-life curriculum that included a hospice care orientation, core articles, and home hospice visits. Evaluated was the impact of the rotation on participant knowledge and attitude. Knowledge was assessed by pretest and posttest questionnaires and compared with more senior resident controls, naïve to the curriculum. Attitudes toward issues relating to end-of-life care and subjective change in knowledge were assessed comparing subjects' retrospective preintervention and postintervention responses included in the postintervention questionnaire. Forty-five second-year participants completed both questionnaires. Participants demonstrated significant improvements in attitude and self-assessed knowledge of end-of-life care in 23 of 24 Likert-type scale questions. The end-of-life curriculum led to significant improvements in participant knowledge and attitudes about the conceptual and practical aspects of end-of-life care. The structure of the rotation should be reproducible in many locales.

Evidence of improved knowledge and skills after an elective rotation in a hospice and palliative care program for internal medicine residents

There is compelling evidence that residents training in primary care need education in palliative care. Evidence for effective curricula is needed. The objective of this study was to test whether a clinical elective improves measures of knowledge and skill. Residents from three categorical training programs in internal medicine were recruited to an elective including clinical experiences in an acute hospital palliative care consultation service, on an acute hospice and palliative care unit, and in-home hospice care. A 25-question pre- and post-test and a videotaped interview with a standardized patient were used to assess communication skills and measure outcomes. Residents demonstrated a 10 percent improvement in knowledge after the four-week elective (p < 0.05). All residents demonstrated basic competency in communication skills at the end of the rotation. These results indicate that clinical rotation shows promise as an educational intervention to improve palliative care knowledge and skills in primary care residents. An important limitation of the study is that it is an elective; further studies with a required rotation and/or a control group are needed to confirm the findings.

Milestones for the Final Mile: Interspecialty Distinctions in Primary Palliative Care Skills Training

CONTEXT

Primary palliative care (PPC) skills are useful in a wide variety of medical and surgical specialties, and the expectations of PPC skill training are unknown across graduate medical education.

OBJECTIVES

We characterized the variation and quality of PPC skills in residency outcomes-based Accreditation Council for Graduate Medical Education (ACGME) milestones.

METHODS

We performed a content analysis with structured implicit review of 2015 ACGME milestone documents from 14 medical and surgical specialties chosen for their exposure to clinical situations requiring PPC. For each specialty milestone document, we characterized the variation and quality of PPC skills in residency outcomes-based ACGME milestones.

RESULTS

We identified 959 occurrences of 29 palliative search terms within 14 specialty milestone documents. Within these milestone documents, implicit review characterized 104 milestones with direct saliency to PPC skills and 196 milestones with indirect saliency. Initial interrater agreement of the saliency rating among the primary reviewers was 89%. Specialty milestone documents varied widely in their incorporation of PPC skills within milestone documents. PPC milestones were most commonly found in milestone documents for Anesthesiology, Pediatrics, Urology, and Physical Medicine and Rehabilitation. PPC-relevant milestones were most commonly found in the Interpersonal and Communication Skills core competency with 108 (36%) relevant milestones classified under this core competency.

CONCLUSIONS

Future revisions of specialty-specific ACGME milestone documents should focus on currently underrepresented, but important PPC skills.

Development and Testing of a New Instrument for Measuring Concerns about Dying in Health Care Providers

A new measure of concerns about dying was investigated in this psychometric study. The Concerns About Dying instrument (CAD) was administered to medical students, nursing students, hospice nurses, and life sciences graduate students ( N = 207) on two occasions; on one occasion they also completed three related measures. Analyses included descriptive statistics, factor analysis, Cronbach’s alpha, test-retest correlations, t tests, and correlations with other measures. Results suggest the CADmeasures three distinct but related areas: general concern about death, spirituality, and patient-related concern about death. Reliabilityestimates were good, and correlations with related measures were strong. Between-group differences suggest scores are related to actual differences in level of concern and beliefs about death and dying. The CAD has the advantage of being very brief, and of explicitly assessing concerns about working with patients who are dying.

Palliative and end-of-life educational practices in US pulmonary and critical care training programs

PURPOSE

To describe educational features in palliative and end-of-life care (PEOLC) in pulmonary/critical care fellowships and identify the features associated with perceptions of trainee competence in PEOLC.

METHODS

A survey of educational features in 102 training programs and the perceived skill and comfort level of trainees in 6 PEOLC domains: communication, symptom control, ethical/legal, community/institutional resources, specific syndromes, and ventilator withdrawal. We evaluated associations between perceived trainee competence/comfort in PEOLC and training program features, using regression analyses.

RESULTS

Fifty-five percent of program directors (PDs) reported faculty with training in PEOLC; 30% had a written PEOLC curriculum. Neither feature was associated with trainee competence/comfort. Program directors and trainees rated bedside PEOLC teaching highly. Only 20% offered PEOLC rotations; most trainees judged these valuable. Most PDs and trainees reported that didactic teaching was insufficient in communication, although sufficient teaching of this was associated with perceived trainee competence in communication. Perceived trainee competence in managing institutional resources was rated poorly. Program directors reporting significant barriers to PEOLC education also judged trainees less competent in PEOLC. Time constraint was the greatest barrier.

CONCLUSION

This survey of PEOLC education in US pulmonary/critical care fellowships identified associations between certain program features and perceived trainee skill in PEOLC. These results generate hypotheses for further study.

Missed opportunities to train medical students in generalist palliative care during core clerkships

BACKGROUND

To improve the quality of care for dying patients, experts have called for all clinicians to be able to provide a generalist level of palliative care. Core clinical clerkships provide an opportunity to incorporate palliative care training to address the lack of required palliative care rotations at most U.S. medical schools.

OBJECTIVE

The objective of this study was to identify and quantify missed opportunities to train third-year medical students in generalist palliative care during required core clerkships.

DESIGN

This study was a cross-sectional survey of third-year students at a leading U.S. medical school without a required palliative care rotation.

MEASUREMENTS

Students completed a survey during the last 4 months of the 2012-2013 academic year quantifying and evaluating their experiences caring for dying patients. Attitudes were assessed using a scale from a national survey of students, residents, and faculty.

RESULTS

Eighty-eight students responded (response rate [RR]=56%). More than one-quarter (26%) never participated in caring for a patient who died. More than one-half (55%) never delivered significant bad news and 38% never worked with a specialist in palliative medicine. Eighty-four percent of students who cared for a patient who died and 60% of students who delivered significant bad news had one or more of those experiences that were not debriefed.

CONCLUSIONS

At an institution without a required palliative care rotation, third-year medical students rarely or never care for patients who die during core clerkships, and when they do, their teams do not debrief or reflect on these experiences. Clinical faculty, including palliative care consultants, can address missed opportunities for palliative care training during core clerkships by augmenting and routinely debriefing students' experiences giving bad news and caring for dying patients.

A comparison of Web-based and small-group palliative and end-of-life care curricula: a quasi-randomized controlled study at one institution

PURPOSE

Few studies have compared the effect of Web-based eLearning versus small-group learning on medical student outcomes. Palliative and end-of-life (PEOL) education is ideal for this comparison, given uneven access to PEOL experts and content nationally.

METHOD

In 2010, the authors enrolled all third-year medical students at the University of California, Davis School of Medicine into a quasi-randomized controlled trial of Web-based interactive education (eDoctoring) compared with small-group education (Doctoring) on PEOL clinical content over two months. Students participated in three 3-hour PEOL sessions with similar content. Outcomes included a 24-item PEOL-specific self-efficacy scale with three domains (diagnosis/treatment [Cronbach alpha=0.92; CI: 0.91-0.93], communication/prognosis [alpha=0.95; CI: 0.93-0.96], and social impact/self-care [alpha=0.91; CI: 0.88-0.92]); 8 knowledge items; 10 curricular advantage/disadvantages; and curricular satisfaction (both students and faculty).

RESULTS

Students were randomly assigned to Web-based eDoctoring (n=48) or small-group Doctoring (n=71) curricula. Self-efficacy and knowledge improved equivalently between groups (e.g., prognosis self-efficacy, 19%; knowledge, 10%-42%). Student and faculty ratings of the Web-based eDoctoring curriculum and the small-group Doctoring curriculum were equivalent for most goals, and overall satisfaction was equivalent for each, with a trend toward decreased eDoctoring student satisfaction.

CONCLUSIONS

Findings showed equivalent gains in self-efficacy and knowledge between students participating in a Web-based PEOL curriculum in comparison with students learning similar content in a small-group format. Web-based curricula can standardize content presentation when local teaching expertise is limited, but it may lead to decreased user satisfaction.

Palliative medicine physician education in the United States: a historical review

In this review we discuss the history of Hospice and Palliative Medicine (HPM) physician education in the United States over the last 20 years, as there has been dramatic growth in our specialty during this time. A Medline literature search was completed and we surveyed leaders in the field of HPM education regarding their experiences in promoting palliative medicine education. Educators were selected based on their peer reviewed publications on key educational initiatives since 1990. A survey tool was designed and emailed to 18 educators across the country and follow-up phone interviews were done to further explore specific questions. The survey and interviews sought information about major palliative care education milestones, instrumental projects, and barriers to further development of palliative medicine education.

Palliative care teaching in medical residency: a review of two POGO-e teaching products

This is a comparison review of GeriaSims and Care of the Aging Medical Patient (CHAMP) modules addressing issues in palliative and hospice medicine found in the Portal of Geriatric Online Education, a free on-line repository of geriatric educational materials for medical educators. GeriaSims is a self-directed teaching module designed to systematically address many of the important questions involved in caring for individuals with chronic progressive and life-limiting illnesses. It is well suited for physicians, particularly medical residents and fellows in-training, who provide care for medically complicated elderly and terminally ill individuals. The CHAMP module is designed to familiarize physician educators with palliative and hospice medicine basics to teach residents and fellows through didactic slides, although it can probably be adapted for use by residents and fellows if audio commentary accompanies the slides. Both modules address practical approaches to addressing palliative care in patients and their families. They are useful teaching tools that address an important learning need and can be readily used to supplement current residency curriculum in hospice and palliative medicine.

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.

Evaluation of Knowledge Among Interns in a Medical College Regarding Palliative Care in People Living with HIV/AIDS and the Impact of a Structured Intervention

BACKGROUND

The evolving nature of palliative care and its renewed role in people living with HIV/AIDS (PLWHA) in the post-HAART (highly active anti-retroviral therapy) era warrants an evaluation of the present curriculum in medical under graduates.

OBJECTIVES

The objectives are(1) to measure the existing knowledge regarding palliative care and its application to PLWHA among medical interns and (2) to measure the impact of a structured intervention on knowledge dimensions.

DESIGN AND SETTING

Interventional repeated measures study.

MATERIALS AND METHODS

A convenience sample of 106 interns in the medical college completed a pre-test assessment and a post-test assessment following a structured intervention for evaluation and comparison of knowledge over three dimensions which were (1) knowledge of palliative care and its application in PLWHA, (2) medical symptoms in PLWHA requiring palliative care and (3) psychosocial needs in PLWHA requiring palliative care.

RESULTS

The mean scores on knowledge showed a consistent increase after the structured intervention and Student's t-test was significant across three dimensions of knowledge of palliative care and its application (t=9.12, P value <0.001), medical symptoms in PLWHA requiring palliative care (t=12.72, P value <0.001) and psychosocial needs in PLWHA (t=11.14, P value <0.001).

CONCLUSION

In spite of the unique challenges presented by the varying course of illness in PLWHA and the variety of needs on the medical, psychosocial and family dimensions, a structured approach and an integrated course curriculum involving principles of both primary and palliative care principles will improve the efficiency of the undergraduate medical education program and enable delivery of effective palliative care interventions and improve quality of life in PLWHA.

Educational needs assessment, development of learning objectives, and choosing a teaching approach

BACKGROUND

How physicians are evaluated throughout their careers and how training programs are accredited has shifted from demonstrating what we teach and what we are learning to demonstrating the achievement of competence.

DISCUSSION

This article discusses some of the components involved with determining and providing necessary educational experiences. These steps apply to various educational needs and settings such as development of curriculum for training programs, clinical staff development, courses in continuing medical education, and identifying learning needs throughout practice. Covered in this article are three components to this process: needs assessment, development of learning objectives, and choosing a teaching approach. A needs assessment is a first step in this process and can be applied to determining revisions in curriculum, identifying needs in clinical staff development, and to self-identifying individual learner status. Once conducted, the identified curriculum needs are linked to the development of learning objectives and outcome statements that identify the knowledge, skills, and attitudes that learners are expected to demonstrate. Finally, understanding of teaching methods is essential to selecting the ones that best fit the identified needs and outcomes of the educational experience.

CONCLUSION

Understanding the separate components involved with learning and curriculum development can ultimately lead to improvement and enrichment of the experiences of learners and educators.

Exposure to death is associated with positive attitudes and higher knowledge about end-of-life care in graduating medical students

OBJECTIVE

To examine the relationship between exposure to death and attitudes and knowledge about end-of-life care in graduating medical students.

PARTICIPANTS AND METHODS

Survey of students graduating from the University of Pittsburgh School of Medicine between 2001 and 2006. Students reported their personal experience with death and their exposure to death and dying patients during medical school. They rated their agreement, on a 4-point Likert scale, with 8 attitude items that were previously used in a national survey. Knowledge about end-of-life care was assessed with a 15-item test about pain and symptom management, ethics, treatment appropriateness, and hospice.

RESULTS

Three hundred and eighty students completed the survey; the response rate was 47%. Seventy-six percent of students reported personal experience with death, and 73% reported caring for dying patients or witnessing a patient's death during their third-year clerkships. Students had positive attitudes about physicians' responsibility and ability to help dying patients and their families, but reported negative emotional reactions to end-of-life care. Students who reported personal or professional experience with death had more positive attitudes and higher knowledge scores than those who did not, p = 0.05.

CONCLUSIONS

Educational initiatives should maximize the time medical students spend caring for dying patients. Teaching students end-of-life care during the course of their clinical clerkships is an effective way to improve attitudes about end-of-life care. Schools should focus on developing emotionally supportive settings in which to teach students about death and dying.

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.

Impact of a postgraduate six-month rotation in palliative care on knowledge and attitudes of junior residents

Fifty junior residents completed a six-month training period. An anonymous postal questionnaire was sent to collect the residents' opinions on improvements in their knowledge, perception of priorities and usefulness of training. Responses were rated from 5 (a great deal) to 1 (not at all improved). A total of 33 (66%) questionnaires were returned. A mean score of 4.48 was obtained on general improvement of knowledge, 4.91 +/- 0.29 on pain control, 4.17 +/- 0.58 on neurological symptoms, 4.09 +/- 0.77 on psychological symptoms, 4.64 +/- 0.60 on communication skills and 4.4 +/- 0.91 on physician attitudes. Some 58% of residents began the training with apprehension, 85% outlined their priorities and 76% reached these objectives. A total of 70% were fully satisfied with the tuition and support received and 98% recommended such clinical rotation. Data suggest that a six-month rotation in palliative care results in high levels of perception of improvement in knowledge and satisfaction. Exposure to palliative care patients during clinical rotations in specialized centres must be encouraged.

The Validity and Reliability of the Affective Competency Score to Evaluate Death Disclosure Using Standardized Patients

OBJECTIVE

To explore the validity and reliability of the affective competency score (ACS), compared to a global rating measure to predict overall competency to perform a death disclosure in a standardized patient exercise and to investigate useful thresholds of the ACS.

METHODS

Thirty-seven fourth-year students underwent standardized patient training in death disclosure during a fourth-year emergency medicine clerkship. Students were evaluated using a checklist, an ACS, and a global rating assessment. ACS interrater reliability, interitem reliability, item-total reliability, and split-half reliability were calculated. Area under the curve (AUC) measurements were used to establish criterion validity.

RESULTS

For the ACS, item-total correlations ranged from 0.76 to 0.85, 0.76 to 0.93, and 0.42 to 0.87; the split-half reliability was 0.82 (p = 0.0001), 0.86 (p = 0.0001) and 0.55 (p = 0.0007) for the standardized patient (SP), the faculty and the medical students, respectively. Interitem correlations were adequate. A moderate interrater correlation of the ACS was observed between the faculty observer and the SP (r = 0.47; p = 0.04); however, the medical students' self evaluation did not correlate significantly with either the SP (r = -0.04; p = 0.79), or the faculty observer (r = 0.00; p = 0.99). The AUC for was 0.98 (95% confidence interval [CI] 0.94 to 1.00), 0.87 (95% CI 0.73 to 0.99), and 0.74 (95% CI 0.53 to 0.95) for the faculty, SP, and medical student, respectively.

CONCLUSIONS

The ACS may be a valid, reliable, and useful measure to assess communication skills by faculty or SPs in this setting. At an ACS score of 16, 19, and 21 points for faculty, SPs, and medical students, respectively, there is 100% specificity for the detection of competency assessed on a global rating. However, the ACS appears to have limited reliability and validity when used by medical students.

Training of Palliative Medicine Fellows: A Report from the Field

BACKGROUND

The escalating demand for palliative care physicians has led to the proliferation of postgraduate fellowship programs to train physicians in the United States and Canada. There is currently little data regarding the extent to which clinical, research, educational or administrative skills and competencies have been incorporated into fellowship training.

OBJECTIVE

The survey aims were to describe: (1) fellows' interests and relative priorities for receiving training in the clinical, educational, research, and administrative aspects of palliative medicine; (2) quantity of training received in each area; (3) fellows' satisfaction with the teaching received in each area; (4) post-fellowship employment experiences.

DESIGN

A survey was conducted via mail and in person, with e-mail utilized for reminders.

SETTING/SUBJECTS

All palliative medicine fellows from the United States and Canada between 1997 and 2002 were surveyed.

MEASUREMENTS

The survey instrument was based on a Health Resources Services Administration (HRSA) survey designed to assess research fellows' educational experiences and training satisfaction and modified to ensure sufficient focus on clinical, education, research and administrative activities; specific palliative medicine content was added.

RESULTS

One hundred one fellows from 24 programs were identified; contact information was obtained from program directors for 89 fellows (88%). Sixty-seven valid surveys were received for a response rate of 75%; 22 programs (14 U.S., 8 Canadian, 92% of active fellowships) are represented. The vast majority of fellows (94%) identified clinical training as very important; 63% identified educational training as important and only few (33% and 21%, respectively) identified research or administrative training as very important. Fellows reported receiving less training on research and administrative topics than they did on clinical or educational topics. Sixty-eight percent of fellows reported spending 10% or less of their time on research activities, and subsequently fellows reported low levels of research competence. Fellows were very satisfied with their clinical training (mean rating = 4.51 on a 5-point scale), intermediately satisfied with their educational training (mean rating = 3.61) and less with their research (mean rating = 3.1) and administrative training (mean rating = 2.24). The largest proportion of fellows (73%) described their first post fellowship position as "clinician/educator" or "full time clinician"; only 14% were "clinician/researchers."

CONCLUSION

Clinical training appears to be both the focus and strength of most palliative care fellowships surveyed. Fellows appear less interested in educational, research, and administrative training and programs appear to be less focused on these aspects of palliative medicine. Fellows also express a lower level of satisfaction with their training in these areas. The scope of fellowship programs must broaden to provide fellows opportunities to develop the research, education and administrative skills necessary to strengthen the research base of the field and provide academic leadership for the future.

Long-Term Evaluation of Required Coursework in Palliative and End-of-Life Care for Medical Students

BACKGROUND

In response to the nationwide need for improved care of patients at end of life, our medical school implemented approximately 20 hours of mandatory coursework on the care of dying patients for all students, with satisfactory completion required for graduation.

OBJECTIVE

We now report a long-term evaluation of this coursework. DESIGN/SUBJECTS/MEASUREMENTS: A 74-item questionnaire concerning attainment of palliative care and other medical school course objectives, postgraduate practice encounters with patients at end of life, and postgraduate behaviors in palliative care was mailed to all students who graduated from our medical school in 2000, 2001, and 2002. Responses were graded by a Likert-type scale. Additionally, the Association of American Medical Colleges Medical School Graduation Questionnaire (AAMC/GQ) reports for all schools and for our medical school were queried for data regarding palliative care.

RESULTS

The return rate of the questionnaire was 54%. The respondents perceived the training to be valuable and effective. They displayed good postgraduate palliative care practices such as choosing to use opiates other than meperidine for pain in the end-of-life setting. Fifty-three percent of the respondents reported that dying patients were often or frequently under their care since graduation. Despite evidence for the efficacy of the training, the respondents perceived that preparedness in certain palliative care domains was somewhat below preparedness in benchmark medical school competencies such as assessment/management of hypertension and diabetes. The AAMC/GQ surveys indicated that for the years 2000-2002, at least 20% more of our graduates perceived that their training in pain management and palliative care was adequate than did all other medical students graduating nationwide.

CONCLUSIONS

The evaluation provides support for the conclusion that mandatory training in palliative and end-of-life care is effective, perceived to be valuable, and contributes to good palliative and end-of-life care practices in our graduates. Furthermore, the training meets a significant demand in our graduates' clinical practice: end-of-life care. However, expanded medical school emphasis and curriculum hours are still needed for palliative care topics, because preparedness in palliative care skills was perceived to be inferior to benchmark medical skills. To our knowledge, this is the first report of a rigorous summative evaluation of the efficacy of required coursework in palliative and end-of-life care in a U.S. medical school curriculum.

Death rounds: end-of-life discussions among medical residents in the intensive care unit

PURPOSE

We introduced "Death Rounds," a monthly discussion of the issues and emotions surrounding the care of dying patients, into the intensive care unit (ICU) rotations for medical house staff. We surveyed participating residents to evaluate their satisfaction with these discussions.

SUBJECTS AND METHODS

Death Rounds occurred at university-based teaching hospitals in Seattle, Washington and Salt Lake City, Utah, between October 2000 and March 2002. Residents who had attended Death Rounds were surveyed in April 2002.

RESULTS

A 10-item survey was distributed by e-mail to 116 residents in Utah and Washington. Of 116 residents, 97 (84%) responded to the survey; 50 of these 97 had attended at least one Death Rounds. Of these 50, the majority reported that Death Rounds were worthwhile (76%) and that sessions should be incorporated into all ICU rotations (76%).

CONCLUSIONS

Death Rounds provide a unique opportunity for residents to discuss the issues raised in caring for dying patients. This conference can be easily incorporated into the ICU curriculum. Most residents who participated in the survey indicated that they valued Death Rounds and believed that it should be included in all ICU rotations.

Bench-to-bedside review: humanism in pediatric critical care medicine - a leadership challenge

A humanistic approach to leadership is especially important in the case of children in the technology-rich intensive care unit (ICU) environment. Leaders should create a humanistic milieu in which the needs of critically ill children, their families and staff are never overlooked. Humanistic leaders are tactful, accessible, approachable and versatile, and have a sense of humour. Humanness in the ICU environment has many faces and poses a challenge to many in leadership positions. Humanistic leaders treat others as they hope they will become. They are constantly questioning themselves, seeking awareness of themselves and others, but most importantly they are constantly learning and evolving. Ultimately, humanistic leadership creates an ICU culture that supports all, is conducive to enriching lives, and is sensitive to the needs of patients and their families.

The palliative care clinical evaluation exercise (CEX): an experience-based intervention for teaching end-of-life communication skills

PURPOSE

To pilot test the "Palliative Care Clinical Evaluation Exercise (CEX)," a new experience-based intervention to teach communication skills in giving bad news and discussing code status. The intervention allows faculty to observe, evaluate, and give feedback to housestaff in their discussions with patients and families.

METHOD

In 2002-03, the intervention was piloted among 60 first-year residents in the categorical Internal Medicine Residency Programs at the University of Pittsburgh. The authors collected feasibility measurements at the time of intervention, and interns' attitudes were measured before and one week after intervention and at the end of the intern year.

RESULTS

Forty-four residents (73%) completed the intervention. Discussions averaged a total of 49.5 minutes (SD 24.1), divided among 12.7 minutes (SD 7.5) for prediscussion counseling between the resident and faculty observer, 25.6 minutes (SD 16.1) for the resident-patient discussion, and 12.1 minutes (SD 5.7) for postdiscussion feedback. Residents rated the Palliative Care CEX favorably (>3 on a five-point scale) on ease of arranging the exercise, educational value, quality of the experience, effect on their comfort with discussions, importance to their education, and value of preceptor feedback. Self-ratings of communication competence showed improvement one week after the intervention.

CONCLUSIONS

The Palliative Care CEX is feasible and positively valued by residents. The findings from this initial pilot study support the value of further efforts to refine the intervention, to confirm its feasibility in other settings, and to validate its use as an educational and assessment tool.

Teaching and learning end-of-life care: evaluation of a faculty development program in palliative care

PURPOSE

To evaluate the effectiveness of the Program in Palliative Care Education and Practice (PCEP), an intensive faculty development program at Harvard Medical School.

METHOD

PCEP is a two-week program offered annually with two on-site sessions in Boston, MA, and an interim period distance-learning component. Training integrates palliative care clinical skill development, learning theory and teaching methods, and leadership and organizational change. Longitudinal surveys (preprogram, retrospective preprogram, and postprogram) of participants from 2000-03 assessed self-reported preparation in providing and teaching palliative care; teaching and patient care practices; and satisfaction with program.

RESULTS

The response rate was 96% (n=149) for Session I and 72% for both Session I and II (n=113). Questionnaire responses demonstrated statistically significant improvements with large effect sizes (range 0.7-1.8) on nearly all measures. Preparation increased from 3.0+/-1.1 to 4.2+/-0.7 for providing end-of-life care (1=not well prepared, 5=very well prepared), and from 2.6+/-1.0 to 4.3+/-0.7 for teaching this topic. Respondents reported behavioral changes in patient care and teaching; e.g., after the program, 63% noted that, specifically as a result of attending the course, they encouraged learners to reflect on their emotional responses to dying patients, and 57% conducted experiential exercises (e.g., role-play). Eighty-two percent rated the experience as "transformative," and many responses to open-ended items described powerful learning experiences. Participants rated the program highly (4.9+/-0.1, 1=lowest, 5=highest rating).

CONCLUSIONS

Integrating clinical content with learning about educational methods is an efficient and effective approach to enhancing clinical faculty's capacity to model and teach clinical care. This program offers an educational model that engages practitioners, stimulates changes in practice, and offers opportunities for reflection and professional revitalization.

Three principles to improve clinician communication for advance care planning: overcoming emotional, cognitive, and skill barriers

BACKGROUND

Medical care of patients with life limiting illness remains fraught with serious deficiencies, including inadequate advance care planning, delayed hospice referral, and continued delivery of aggressive treatment that is overtly counter to patients' preferences.

OBJECTIVE

This paper describes clinicians' emotional, cognitive, and skill barriers to shared decision-making with seriously ill patients and their loved ones.

DESIGN

Thematic literature review.

RESULTS

Based on a literature review, as well as clinical and educational experience, we articulate three principles to address these barriers and guide future professional communication training for advance care planning.

CONCLUSIONS

We argue that these barriers must be overcome before deficiencies in end-of-life care can be fully ameliorated.

There Is Hope for the Future: National Survey Results Reveal that Geriatric Medicine Fellows Are Well-Educated in End-of-Life Care

OBJECTIVES

To assess the status of geriatric medicine (GM) fellows' training experiences in end-of-life care via self-report.

DESIGN

Anonymous surveys completed by mail, Web access, and telephone.

SETTING

U.S. accredited GM fellowship training programs.

PARTICIPANTS

Two hundred ninety-six surveys were sent to graduating GM fellows in 1- and 2-year programs across the Unites States.

MEASUREMENTS

Measurements assessed self-reported attitudes, quantity and quality of end-of-life care education, preparation to provide care, and perceived value of caring for dying patients.

RESULTS

Response rate was 74%. Ninety-five percent or more of respondents held positive views about physicians' responsibility and ability to help dying patients. Seventy percent of fellows had completed a rotation focused on end-of-life care. Fellows who had done such rotations rated their end-of-life care education as highly as their overall geriatrics training. Fellows frequently received teaching in many end-of-life care topics, with lower rates of teaching how to say goodbye and responding to requests for assisted suicide. Overall, fellows felt well prepared to care for dying patients. Four factors independently predicted such preparedness: having had a palliative or end-of-life care rotation, being female, having been taught how to say goodbye to patients, and perceiving that it is important to attending physicians that fellows learn to care for dying patients.

CONCLUSION

GM fellows feel their end-of-life care education is excellent and feel prepared to take care of dying patients. It is critical that geriatricians in training have access to and take advantage of palliative and end-of-life care rotations.

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.

Education in palliative care

Palliative care education includes the domains of pain and nonpain symptom management, communications skills, ethics and law, psychosocial care, and health systems. Defining key attitudes, knowledge, and skill objectives, and matching these to appropriate learning formats, is essential in educational planning. Abundant educational resource material is available to support classroom and experiential palliative care training.

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.

Interdisciplinary education: evaluation of a palliative care training intervention for pre-professionals

PURPOSE

Medical education inadequately prepares students for interdisciplinary collaboration, an essential component of palliative care and numerous other areas of clinical practice. This study developed and evaluated an innovative interdisciplinary educational program in palliative care designed to promote interdisciplinary exchange and understanding.

METHOD

The study used a quasi-experimental longitudinal design. Thirty-three medical students (third and fourth year) and 38 social work students (second year of masters degree) were recruited. The intervention group students (21 medical and 24 social work students) participated in a series of four training sessions over four weeks while the control group students received written materials after the study. The curriculum and teaching methods were based on theories of professional socialization and experiential learning. The intervention included experiential methods to promote interdisciplinary interaction to foster communication, exchange of perspectives, and the building of mutual trust and respect. Both groups completed assessments of perceived role understanding, a primary component of effective interdisciplinary teamwork, in palliative care. Self-administered surveys were completed at baseline, intervention completion, and three months later. The intervention group also completed an anonymous evaluation about the interdisciplinary education.

RESULTS

The intervention group demonstrated a significant increase in perceived role understanding compared with the control group. Three-month follow-up data suggested that intervention group subjects maintained gains in perceived role understanding.

CONCLUSION

An interdisciplinary educational intervention improves role understanding early in the process of professional socialization in a pilot program. Further implementation of interdisciplinary education should evaluate the effect on subsequent interdisciplinary practice and the quality of patient care.

End-of-life care in the curriculum: a national study of medical education deans

PURPOSE

To describe attitudes and practices of end-of-life care teaching in the undergraduate medical curriculum in the United States as reported by administrative leadership and identify opportunities for improvement.

METHOD

A telephone survey of associate deans for medical education or curricular affairs at a random sample of 62 accredited U.S. medical schools was conducted in 2002.

RESULTS

Fifty-one deans participated (82% response rate). Most (84%) described end-of-life care education as "very important" and supported incorporating more end-of-life care teaching into the undergraduate curriculum. Sixty-seven percent reported that insufficient time is currently given to palliative care in their curriculum. Although a majority opposed required courses (59%) or clerkships (70%) that focused on end-of-life care, they did unanimously endorse integrating teaching end-of-life care into existing courses or clerkships. Key barriers to incorporating more end-of-life care into the curriculum included lack of time in the curriculum, lack of faculty expertise, and absence of a faculty leader.

CONCLUSION

Associate deans for medical education or curricular affairs in the United States support integrating end-of-life care content into existing courses and clerkships throughout the undergraduate medical curriculum. Successful integration will require institutional investment in faculty development, including both the development of faculty leaders to drive change efforts, and the education of all faculty who teach students and exert influence as role models and mentors. The strong support for end-of-life care education expressed by academic leaders in this study, combined with the high level of interest expressed in the authors' 2001 national survey of students, provide evidence of the potential for meaningful change in the undergraduate medical curriculum.

Development of a medical subspecialty in palliative medicine: progress report

There is significant interest in seeking professional recognition of expertise in caring for people with serious life-threatening illness and their families through creation of a specialty in palliative medicine. Certification of physicians and accreditation of training programs are key elements for formal recognition. The American Board of Hospice and Palliative Medicine was established to achieve these goals. The next step in the maturation of the subspecialty of palliative medicine is to have both the certification and the accreditation recognized by the professional self-governing bodies in organized medicine. This paper answers common questions about obtaining recognition by the Accreditation Council of Graduate Medical Education, the American Board of Medical Specialties and its member boards. Formal recognition of the subspecialty of palliative medicine is sought in order to extend the knowledge and skills inherent in the domains of palliative medicine. Such recognition will also encourage more physicians to enter the field and assure standards of care for those patients and their families who need it.

End-of-life education using the dramatic arts: the Wit educational initiative

Caring for dying persons requires skill in interpersonal aspects of care, which may be difficult to teach using conventional educational methods. The Pulitzer Prize-winning play Wit relates the personal story of a patient dying from metastatic ovarian cancer and describes the protagonist's experience with medical care from diagnosis to death. Members of the Department of Medicine at the VA Greater Los Angeles Health care System and the David Geffen School of Medicine, UCLA developed a program that utilized Wit to educate medical students, residents, and staff providers in the humanistic elements of end-of-life care. Between February 2000 and January 2002 the Wit Educational Initiative organized on-site readings of Wit by local professional theatre companies at medical centers throughout the United States and Canada, inviting medical students, housestaff, and other providers to attend the play followed by structured discussions of the play's themes. The Initiative provided extensive support for potential program sites including publicity, providing a handbook with a step-by-step guide to organizing local programs, and feedback of postperformance survey results. The Initiative was successful in organizing performances at 32 out of 54 (59%) medical centers where a local production of Wit was identified. Survey respondents confirmed the appeal, emotional impact, and perceived relevance of drama in end-of-life education. An educational program using theatre to educate trainees in the humanistic aspects of end-of-life care was enthusiastically received by medical schools and rated highly by attendees.

An End-of-life Curriculum: Empowering the Resident, Patient, and Family

Physician training programs in undergraduate and graduate medical education strongly recommend that their trainees gain experience in helping patients and their families address end-of-life and palliative care issues with knowledge and compassion. Currently these training programs are inadequately meeting this goal. This paper describes a creative 1-day training workshop or several half-day seminars on the end of life, which are delivered as part of our family practice intern orientation. The training includes self-awareness about death, communicating bad news, guidance with paperwork and legal issues, the stages of grief, patient's perspectives on dying, hospice, and physician well-being.