Professional education in end-of-life care: a US perspective

The development and piloting of a goals of care conversation education program for an advanced illness population

Ten thousand Americans turn 65 daily. With age, individuals are confronted by complex medical modalities which can be difficult to understand and potentially burdensome. Historically, clinicians lacked the education, skill, and comfort level to identify the need for and address the patient's goals of care (GoC). Inter-professional content experts convened to develop a comprehensive program to educate and increase the comfort level of clinicians when having GoC conversations. The goal was to provide structured guidance to increase the practitioners' level of confidence in engaging patients/families in these conversations. A multimodal educational methodology using simulation was chosen as a learning strategy permitting clinicians to practice GoC conversations while receiving immediate feedback. A five hour inter-professional educational program called Goals of Care Conversation Education Program® (GoCCEP™) was developed and piloted. The GoCCEP^TM's evaluations demonstrate success giving clinicians necessary tools and a safe practice environment increasing knowledge and confidence to have substantive GoC conversations.

Continuing professional development for volunteers working in palliative care in a tertiary care cancer institute in India: a cross-sectional observational study of educational needs

Context:

Training programs for volunteers prior to their working in palliative care are well-established in India. However, few studies report on continuing professional development programs for this group.

Aims:

To conduct a preliminary assessment of educational needs of volunteers working in palliative care for developing a structured formal continuing professional development program for this group.

Settings and Design:

Cross-sectional observational study conducted in the Department of Palliative Medicine of a tertiary care cancer institute in India.

Materials and Methods:

Participant volunteers completed a questionnaire, noting previous training, years of experience, and a comprehensive list of topics for inclusion in this program, rated in order of importance according to them.

Statistical Analysis Used:

Descriptive statistics for overall data and Chi-square tests for categorical variables for group comparisons were applied using Statistical Package for Social Sciences version 18.

Results:

Fourteen out of 17 volunteers completed the questionnaire, seven having 5–10-years experience in working in palliative care. A need for continuing professional development program was felt by all participants. Communication skills, more for children and elderly specific issues were given highest priority. Spiritual-existential aspects and self-care were rated lower in importance than psychological, physical, and social aspects in palliative care. More experienced volunteers (>5 years of experience) felt the need for self-care as a topic in the program than those with less (<5-years experience) (P < 0.05).

Conclusions:

Understanding palliative care volunteers’ educational needs is essential for developing a structured formal continuing professional development program and should include self-care as a significant component.

Student Nurses Learning about Death, Dying, and Loss: Too Little, Too Late?

Concerns about the care provided to people dying from life-threatening illness have prompted a number of international reforms to improve the quality of palliative and end-of-life (EOL) care. The majority of this care is provided by nurses. They spend more time with dying patients than any other health professionals and therefore, need specific clinical skills and knowledge. Palliative and EOL care education is increasingly being positioned as a specialism, available only to a small number of registered nurses as part of continuing professional development. However, increasing numbers of patients with life-threatening illness are being treated in non-specialist settings by nurses with a generalist education. Furthermore, undergraduate nurse education has traditionally had a limited focus on palliative and EOL care, hence claims that undergraduate nursing curricula are inadequate. Drawing on an international literature, this review explores the evidence about the adequacy of undergraduate curricula in this area. It considers the extent to which palliative and EOL curriculum is included in undergraduate nurse education and draws upon evidence from students and registered nurses, who as consumers of education, report feeling unprepared to care for and communicate with, dying patients.

An Integrated Literature Review of Death Education in Pre-Registration Nursing Curricula: Key Themes

Recent policy has raised the profile of end-of-life care internationally, with the aim of increasing access to quality care for everyone experiencing life-limiting illness. This reflects an international shift in the provision of palliative care to encompass chronic conditions other than cancer. Nurses have an important role in delivering this care and need to be equipped with particular knowledge and skills. However, pre-registration nursing curricula have traditionally had a limited emphasis on death and dying and nurses report feeling unprepared to care for dying patients. This has led to claims that death education in pre-registration curricula is inadequate. This integrated review explores the published literature that reports on death education within pre-registration nurse education. Presenting an international overview, the aim of the review is to contribute to knowledge about the nature and extent of death education in pre-registration curricula. In the context of this paper, death education encompasses both palliative and end-of-life care. Electronic searches of major bibliographic databases found inconsistencies across educational provision with variations in quantity, content, and approach. Despite an increasing amount of death education in pre-registration curricula, there remains a deficit in key areas such as knowledge, skills, organisation of care, and teamwork.

Efficacy of the End-of-Life Nursing Care Continuing Education Program for Nurses in General Wards in Japan

This study aimed to examine effectiveness of the End-of-life nursing care continuing education program for general ward nurses. A nonrandomized, before-after trial was conducted. The program was implemented for 25 nurses. The contents of the program consisted of the family assessment, general symptom management and practical use of theories and models regarding end-of-life nursing care. The primary outcome, implementation ability of end-of-life nursing care, was significantly improved after the program; improvements continued even at 2 months after. Similar results were obtained for nurses' confidence and knowledge concerning end-of-life nursing care. As for attitude toward end-of-life care, participants' scores were further elevated after the program. The participants rated the usefulness of the program as high. The effectiveness of the program was suggested from these results. In the future, this program should be widely used for in-service training.

Do residents need end-of-life care training?

Objective:

As medical education evolves, emphasis on chronic care management within the medical curriculum becomes essential. Because of the consistent lack of appropriate end-of-life care training, far too many patients die without the benefits of hospice care. This study explores the association between physician knowledge, training status, and level of comfort with hospice care referral of terminally ill patients.

Method:

In 2011, anonymous surveys were distributed to physicians in postgraduate years 1, 2, and 3; fellows; hospital attending physicians; specialists; and other healthcare professionals in five hospitals of a large health system in New York. Demographic comparisons were performed using χ2 and Fisher's exact tests. Spearman correlations were calculated to determine if professional status and experience were associated with comfort and knowledge discussing end-of-life topics with terminal patients.

Results:

The sample consisted of 280 participants (46.7% response rate). Almost a quarter (22%) did not know key hospice referral criteria. Although 88% of respondents felt that knowledge of hospice care is an important competence, 53.2% still relinquished advance directives discussion to emergency room (ER) physicians. Fear of patient/family anger was the most frequently reported hospice referral barrier, although 96% of physicians rarely experienced reprisals. Physician comfort level discussing end-of-life issues and hospice referral was significantly associated with the number of years practicing medicine and professional status.

Significance of results:

Physicians continue to relinquish end-of-life care to ER staff and palliative care consultants. Exploring unfounded and preconceived fears associated with hospice referral needs to be integrated into the curriculum, to prepare future generations of physicians. Medical education should focus on delivering the right amount of end-of-life care training, at the right time, within the medical school and residency curriculum.

Factors and Structural Model Related to End-of-Life Nursing Care in General Ward in Japan

This study aimed to determine the factors related to the implementation of end-of-life nursing care in general wards and to examine the adequacy of the hypothetical care implementation model. A cross-sectional survey was conducted. As the results of multiple regression analysis, 8 factors were determined: subjective evaluation of nurses’ own team, positive attitudes toward caring for dying persons, existence of a role model, death relief (Death Attitude Inventory), knowledge of symptom management knowledge of family assessment, abstract judgment skill, and participation in the seminar. The hypothetical model was constructed using these factors, and the adequacy of this model was confirmed by a structural equation modeling. These factors and the model would give suggestions of educational content and its method, which should be provided to general ward nurses.

Twenty-First Century End-of-Life Issues in Selected U.S. Professional Schools

Health professionals often relate to dying and death, but what does their professional training do to prepare them for these often stressful situations? With this question in mind, selected professional schools (medical, nursing, dental, child life, and veterinary) were surveyed to determine their emphasis on end-of-life issues in the 21st century. Return rates ranged from 71 to 100%. With the exception of dental schools, over 96% offer “something” on end-of-life issues. The lecture format and interdisciplinary background of the instructors frequently occur, with medical schools tending to be the most interdisciplinary. Topics covered vary, though attitudes toward death and dying, communication with the family and patient/owner of the animal, social and psychological contexts of dying, the experience of dying, and grief and bereavement are especially often addressed.

Thanatophobia in medical students: approach to death and dying patients attitude scale (ADDPAS) for undergraduate years in medicine

In recent decades growing efforts in Western countries in integrating end-of-life care issues into undergraduate medical education have been conspicuous. However, studies in this field are limited in Turkey. We aimed, therefore, as a first step, to develop an attitude scale in order to obtain objective data regarding medical students' approaches to death and dying patients. After applying the scale on medical students and performing exploratory factor analysis, it was found out to be composed of a two-dimensional structure. Then the internal construct validity of these dimensions was subjected to Rasch analysis and the reliability of them was tested by internal consistency and person separation index. As a result of overall analyses, we suggest a new scale which is capable of making valid and reliable measurements.

The impact of a clinical rotation in hospice: medical students' perspectives

Medical educators agree that training in end-of-life care (EOLC) must be an integral part of medical education at all levels. While progress in this area of education has taken place, many gaps still exist. This article describes the self-reported impact of a required one-week hospice rotation for third-year medical students. Students completing their hospice rotation during a one-year period were asked to write an essay describing the most important lessons they learned. Qualitative analyses of the essays revealed 10 core themes and generated a coding schema for detailed analysis. Students' essays reflected knowledge gained, emotional reactions, cognitive insights, and relationship-centered skills. Comments focused on the following themes: benefits and philosophy of hospice; impact on future practice; interdisciplinary team approach; management of pain and suffering; facts about hospice; personal impact; communication with patients and families; dedication and skill of staff; role of families; and value of home care. Students consistently recognized the significance of positive role models. Learning about a new field of medicine helped broaden students' knowledge, skills, and beliefs, and expanded their assumptions about illness and suffering, the role of health care professionals, and the goals of medicine. Reflection and writing brought about self-awareness of the learning process itself. The study demonstrates that a robust clinical EOLC exposure can be effectively incorporated into undergraduate education and that student self-reports constitute a valuable mode of evaluation. Longitudinal assessments of trainees' competencies in EOLC are needed to optimize these educational endeavors.

End-of-life education in the pre-registration nursing curriculum: Patient, carer, nurse and student perspectives

Providing good quality care for dying patients has been highlighted as a national priority in the UK. The Department of Health’s end-of-life (EOL) care strategy outlines how patients should be cared for to ensure that they experience a ‘good death’. Nurses have an important role to play in the delivery of EOL care and need to be knowledgeable about the palliation of symptoms and the social context of death and dying. Traditionally, the pre-registration nursing curriculum has had a limited emphasis on EOL care. While there have been significant developments in nurse education in the last decade, the amount of EOL content in nurse education remains inadequate. Drawing on literature mainly from the UK and USA, this review explores from the perspectives of students, newly qualified nurses, patients and carers the outcomes of EOL education. It reviews the evidence to determine whether newly qualified nurses are adequately prepared to deliver quality care to patients at the end of their lives. The evidence suggests that despite a greater emphasis on EOL care in nurse training, adequately preparing nurses remains a challenge to educators.

Pediatric residents' and fellows' perspectives on palliative care education

BACKGROUND

The American Academy of Pediatrics recommends that pediatricians become knowledgeable in and comfortable with providing palliative care.

OBJECTIVE

The study goals included: determining the extent of training, knowledge, experience, comfort and competence in palliative care communication and symptom management of pediatric residents and fellows; obtaining residents' and fellows' views on key palliative care concepts; identifying topics and methods for palliative care education; and identifying differences in responses between residents and fellows.

DESIGN/METHODS

In academic year 2006-2007 pediatrics residents and fellows completed a survey on: training, experience, knowledge, competence, and comfort in delivering palliative care; palliative care practices; and suggestions for delivering palliative care education.

RESULTS

Fifty-two (60%) and 44 (62%) residents and fellows respectively completed the survey. Residents and fellows described none to moderate levels of training, experience, knowledge, competence and comfort in palliative care. Most respondents said they would benefit from more formal palliative care training. Respondents identified discussing prognosis, delivering bad news, and pain control as the three most important areas of needed education. Learning about supporting families spiritually and emotional support for physicians were among the least important educational areas identified. Respondents recommended delivering education via observation, bedside teaching, and participation in multidisciplinary groups.

CONCLUSIONS

Efforts to improve education in pediatric palliative care are needed. A palliative care team could facilitate palliative care education through engaging trainees in "real-life" interactions. The role of physicians in providing spiritual support and the need for educating physicians in obtaining emotional support for themselves merit further investigation.

End-of-Life Care Curricula in Undergraduate Medical Education: A Comparison of Allopathic and Osteopathic Medical Schools

End-of-life care curricula in osteopathic medical schools were compared with allopathic school offerings. An 8-question online survey of undergraduate medical education administrators at all United States osteopathic medical schools (n = 26) and 26 allopathic schools geographically closest to them was conducted in 2007. Responses from 80% (n = 21) of osteopathic schools and 77% (n = 20) of allopathic schools revealed that both osteopathic and allopathic medical schools offered end-of-life care education. Of note is that 71% of the osteopathic medical school respondents had a course that concentrates on end-of-life care compared with 37% of allopathic school respondents ( P = .03). This disparity in percentages may be due to a number of reasons, 2 of which may include course identification methods and the primary care orientation and philosophy inherent in osteopathic medical schools.

Palliative care and end of life issues in UK pre-registration, undergraduate nursing programmes

Palliative and end of life care topics have traditionally not been in nursing school curricula. Only in recent years have these been included. The aim of this research was to determine the current status of such an emphasis in programmes in the United Kingdom (UK). A mailed survey in 2006 to the 66 undergraduate (pre-registration) nursing programmes in the UK (return rate of 79%) determined that palliative and end of life care play a significant role in these programmes. Forty-five teaching hours on average were devoted to these topics. All of the schools have some provision on palliative and end of life care, and over 95% of students participated in these courses. A nurse was usually the primary instructor, although non-nurses were sometimes used. Attitudes toward dying and death and communicating with terminally-ill patients and family members were emphasised. By highlighting dying and death in the curricula, nursing schools appeared to be giving nursing students an opportunity to face the issue of death, thus helping them to be better prepared to help their patients and their families to do so.

End-of-life content in Comprehensive Cancer Control Plans: a systematic review

A recent project to define public health priorities for end of life (EOL) recommends incorporating EOL principles in all state/territory/tribe Comprehensive Cancer Control (CCC) Plans. The degree to which EOL content is currently included in CCC Plans was assessed through a systematic review of CCC Plans, examining keywords, definitions, topics, data, goals, and strategies. Forty-five plans (42 state, 3 tribal) were eligible. Forty-one CCC Plans (91%) included the keyword "end-of-life." EOL goals were most often categorized as use of care, access to care, and awareness of EOL issues among patients/public and providers. The top EOL strategies were research, provider education, and patient/public education. The results establish a baseline of EOL content in CCC Plans and should help improve assistance in future CCC planning efforts.

End-of-life and palliative care issues in medical and nursing schools in the United States

Medical and nursing schools in the United States have traditionally had a limited emphasis on end-of-life care. The present study is a comparison of these 2 professional programs' current offerings on death education. Data were gathered via a mailed survey from the 122 medical schools in 2005 and the 580 baccalaureate nursing programs in 2006. Return rates of 81% and 71%, respectively, were received. All medical schools and 99% of nursing schools reported offering something on death and dying, with over 90 % of students in these programs participating. The average number of hours offered in both professional programs is less than 15. Over 87% in both programs have offerings in palliative care. Whereas nursing programs rely almost solely on nurses for end-of-life course provisions, medical schools are more interdisciplinary by faculty. End-of-life issues are presented in both medical and nursing curricula, though on a limited basis. This emphasis exposes students to the issues, though not in an in-depth way.