Does special education in palliative medicine make a difference in end-of-life decision-making?

A Qualitative Study of Stakeholders' Perspectives of Implementing Interprofessional Shared Decision-Making Education in Palliative Care

Introduction Shared decision-making (SDM) in palliative care is a highly complex process that requires an interdisciplinary team. Interprofessional team members need education on how to facilitate discussion of patient/family wishes at the end of life in hospital settings. So far, interprofessional shared decision-making (IP-SDM) education frameworks have been used to a limited extent in the area of education on palliative care. The aim of this study was to explore policymakers', health professionals', faculty members', and students' perspectives on implementing an IP-SDM educational framework in palliative care to identify aspects that should be prioritized to further develop interprofessional education for SDM in palliative care. Methods We used the qualitative method to capture the micro, meso, and macro factors using Oandasan and Reeves' model for the implementation of IP-SDM education regarding palliative care. Data collection tools included in-depth, face-to-face interviews with individual policymakers and focus group interviews with health professionals, faculty members, and undergraduate health professionals. The interview guide explores the teaching of SDM in palliative care, factors that could facilitate or hinder the implementation of IP-SDM education for health professions students in palliative care, and interventions to facilitate the implementation of this approach. This study was conducted at the Oncology and Palliative Care Department at King Abdulaziz Medical City in the Ministry of National Guard Health Affairs and at King Saud bin Abdulaziz University for Health Sciences in Jeddah, Saudi Arabia. Results The results indicated a high demand for IP-SDM in palliative care. The findings revealed factors that can facilitate or hinder the implementation of IP-SDM education in palliative care for undergraduate health professions students that is going to the local community. Factors include culture, religion, gender, power issues, team hierarchy, and respect among team members. Also, our findings have revealed potential solutions to the hindering factors. Conclusions IP-SDM education in palliative care is a highly relevant topic for improving patient outcomes. However, it might be a complex process to implement, especially given the challenges of palliative care settings. We recommend starting such a course in the early clinical phases of undergraduate health professional education.

'Now I can train myself to be with death': a phenomenological study with young doctors in care homes supported by a palliative care unit during the second wave of the pandemic in Italy

OBJECTIVE

During the second wave of the COVID-19 pandemic, one of the organisational strategies established by the Italian National Health System was the special units for continuity of care (SUCCs). In the province of Ravenna, those units enrolled novice doctors to care for elderly patients with COVID-19 in care homes (CHs). The local palliative care (PC) unit decided to offer consultations and support to them. This study aimed to comprehend the experience of young doctors who asked for consultations when facing, during their first early years of practice, complex situations.

DESIGN

We conducted a qualitative study employing a phenomenological approach and in-depth interviews.

PARTICIPANTS

We involved 10 young doctors who worked in Italian SUCC during the pandemic and used a PC consultation support service.

RESULTS

What describes our participants' experience is related to four main themes: (1) reducing distances, (2) perceiving medical futility and improvising, (3) being supported to learn how to be with death and (4) narrowed timing to humanise care. The pandemic was, for our participants, a moment of reflection and critique on the skills acquired during the university course. It was a strong experience of human and professional growth that helped them reshape and deepen their role and skills, incorporating the approach of PC into their professional identity.

CONCLUSIONS

Integration between specialists and young doctors with an early entry into the workforce during the pandemic in CHs set out a 'shift' to a proactive and creative approach through a new awareness of professional and personal roles in doctor-patient relations. The continuity of care models should be rethought by integrating CHs and PC. Adequate PC training for young doctors (at pregraduate and postgraduate levels) can change doctors' vision and daily practice in assisting patients at the end of life.

Building the Nigerian Palliative Care Workforce: An Interdisciplinary Distance Learning Training Program

Background:

Education and capacity building in palliative care are greatly needed in Nigeria. Currently, two institutions integrate palliative care into the undergraduate medical curriculum and no post graduate training exists. A team from the University of Lagos in Nigeria and Northwestern University in the US collaborated to design, implement, and evaluate a 12-hour virtual palliative care training program for Nigerian health professionals.

Objective:

This study investigated the impact of the first session of the training program on healthcare professionals’ knowledge, skills, attitudes, and confidence in palliative care.

Methods:

The Education in Palliative and End-of-Life (EPEC) curriculum and the Kenya Hospices and Palliative Care Association (KEHPCA) curriculum were used as foundations for the program and adapted for the Nigerian context. Delivered online, the training focused on goals of palliative care, whole patient assessment, communication skills, pain management, psychosocial issues, palliative care in COVID, oncology, and HIV. A mixed-methods evaluation based on Kirkpatrick’s evaluation framework was used and data were gathered from surveys and focus groups.

Findings:

Thirty-five health professionals completed the training. The training had a positive impact on knowledge, skills, and attitudes. Confidence in providing end-of-life care increased from 27.3% to 92.9% while confidence in prescribing medication to relieve symptoms at the end of life increased from 42.9% to 92.0%. Performance on multiple-choice knowledge tests increased by 10% (p < 0.01). All participants stated that they would recommend the program to a peer while 96.4% reported the program was relevant to the Nigerian context. Qualitative analysis suggested that the training would help participants provide more holistic care for patients, communicate better, and change how they interacted with families. Topics to be addressed in future training were identified.

Conclusions:

This virtual training can be an important element in palliative care capacity building in Nigeria and represents a model for global health collaboration.

Physicians' decreased tendency to choose palliative care for patients with advanced dementia between 1999 and 2015

Background

Physicians’ decision-making for seriously ill patients with advanced dementia is of high importance, especially as the prevalence of dementia is rising rapidly, and includes many challenging ethical, medical and juridical aspects. We assessed the change in this decision-making over 16 years (from 1999 to 2015) and several background factors influencing physicians’ decision.

Methods

A postal survey including a hypothetical patient-scenario representing a patient with an advanced dementia and a life-threatening gastrointestinal bleeding was sent to 1182 and 1258 Finnish physicians in 1999 and 2015, respectively. The target groups were general practitioners (GPs), surgeons, internists and oncologists. The respondents were asked to choose between several life-prolonging and palliative care approaches. The influence of physicians’ background factors and attitudes on their decision were assessed.

Results

The response rate was 56%. A palliative care approach was chosen by 57 and 50% of the physicians in 1999 and 2015, respectively (p = 0.01). This change was statistically significant among GPs (50 vs 40%, p = 0.018) and oncologists (77 vs 56%, p = 0.011). GPs chose a palliative care approach less often than other responders in both years (50 vs. 63% in 1999 and 40 vs. 56% in 2015, p < 0.001). In logistic regression analysis, responding in 2015 and being a GP remained explanatory factors for a lower tendency to choose palliative care. The impact of family’s benefit on the decision-making decreased, whereas the influence of the patient’s benefit and ethical values as well as the patient’s or physician’s legal protection increased from 1999 to 2015.

Conclusions

Physicians chose a palliative care approach for a patient with advanced dementia and life-threatening bleeding less often in 2015 than in 1999. Specialty, attitudes and other background factors influenced significantly physician decision-making. Education on the identification and palliative care of the patients with late-stage dementia are needed to make these decisions more consistent.

Barriers and facilitators to palliative care education in nursing and residential homes: a rapid review

BACKGROUND

There is insufficient high-quality evidence to suggest that palliative care education can impact care home settings.

AIMS

To identify, appraise and synthesise all available evidence on the barriers and facilitators to providing palliative care education in residential and nursing care homes and to generate recommendations to increase the effectiveness of future palliative care education programmes in care homes.

METHODS

A rapid review searching CINAHL, Medline and ProQuest. One author screened full-text articles for inclusion. Any uncertainties were discussed with a second author.

FINDINGS

Twenty-two articles were included in the full review. Analysis of the included articles revealed the following overlapping themes: structural systems; cultural and personal issues; and knowledge translation issues with interaction.

CONCLUSION

Addressing the barriers and facilitators when designing palliative care education programmes for care homes will lead to more successful outcomes.

Palliative care education in the undergraduate medical curricula: students' views on the importance of, their confidence in, and knowledge of palliative care

Background

The need for palliative care is increasing. Since almost every junior doctor will come across palliative care patients, it is important to include palliative care in the undergraduate curriculum. The objective of this research is to gather undergraduate students’ views on palliative care in terms of its importance, their confidence in and knowledge of the domain.

Methods

Final-year medical students at four Dutch medical faculties were surveyed. The questionnaire measured their views on the education they had received, their self-reported confidence in dealing with palliative care patients and their knowledge of palliative care.

Results

Two hundred twenty-two medical students participated in this study. Students considered palliative care education relevant, especially training in patient-oriented care and communication with the patient. Students felt that several topics were inadequately covered in the curriculum. Overall, the students did not feel confident in providing palliative care (59.6%), especially in dealing with the spiritual aspect of palliative care (77%). The knowledge test shows that only 48% of the students answered more than half of the questions correctly.

Conclusion

The students in this study are nearly junior doctors who will soon have to care for palliative patients. Although they think that palliative care is important, in their opinion the curriculum did not cover many important aspects, a perception that is also in line with their lack of confidence and knowledge in this domain. Therefore, it is important to improve palliative care education in the medical curriculum.

Does Decision-making in End-of-life Care Differ Between Graduating Medical Students and Experienced Physicians?

BACKGROUND/AIM

Appropriate decision-making in end-of-life (EOL) care is essential for both junior and senior physicians. The aim of this study was to compare the decision-making and attitudes of medical students with those of experienced general practitioners (GP) regarding EOL-care.

MATERIALS AND METHODS

A questionnaire presenting three cancer patient scenarios concerning decisions and ethical aspects of EOL-care was offered to 500 Finnish GPs and 639 graduating medical students in 2015-2016.

RESULTS

Responses were received from 222 (47%) GPs and 402 (63%) students. The GPs withdrew antibiotics (p<0.001) and nasogastric tubes (p=0.007) and withheld resuscitation (p<0.001), blood transfusions (p=0.002) and pleural drainage (p<0.001) more often than did the students. The students considered euthanasia and assisted suicide less reprehensible (p<0.001 in both) than did the GPs.

CONCLUSION

Medical students were more unwilling to withhold and withdraw therapies in EOL-care than were the GPs, but the students considered euthanasia less reprehensible. Medical education should include aspects of decision-making in EOL-care.

Intra- and Inter-Physician Agreement in Therapeutic Decision for Sleep Apnea Syndrome

BACKGROUND

Large variation in diagnostic procedures and treatment recommendations may hinder the management of obstructive sleep apnea (OSA) and also compromise correct interpretation of the results of multicenter clinical trials, especially in subjects with non-severe OSA. The aim of this study was to analyze the therapeutic decision-making between different sleep physicians in patients with AHI<40events/h.

METHODS

Six experienced senior sleep specialists from different sleep centers of Spain were asked to make a therapeutic decision (CPAP treatment) based on anonymized recordings of patients with suspected OSA that has previously performed a sleep study. The clinical data was shown in an online database and included anthropometric features, clinical questionnaires, comorbidities, physical examination and sleep study results. Intra- and inter-observer decision-making were analyzed by the Fleiss' Kappa statistics (Kappa).

RESULTS

A total of 720 medical decisions were taken to analyze the agreement between sleep professionals. Overall intra-observer evaluation reliability was almost perfect (Kappa=0.83, 95% CI, 0.75-0.90, p<0.001). However, overall inter-observer concordance decreased to moderate agreement (Kappa=0.46, 95% CI, 0.42-0.51, p<0.001). Nevertheless, it was especially low when considering AHI<15events/h.

CONCLUSIONS

This study demonstrates a good intra-observer concordance in the therapeutic decision-making of different sleep physicians treating patients with low/moderate OSA. However, when analyzing inter-observer agreement the results were considerably worse. These findings underline the importance of developing improved consensus management protocols.