PURPOSE: To examine the effect of education on nursing personnel's knowledge and attitudes regarding the use of hand massage, breathing techniques, and essential oils with hospice and palliative care patients.
BACKGROUND: Unrelieved, end of life pain is common among hospitalized patients on hospice and palliative care units. Integrative care techniques such as hand massage, breathing techniques, and essential oils can be available to use with these individuals. Nursing personnel are often unaware of other techniques that are not a traditional pharmacology approach to pain.
METHODS: A quasi-experiment was conducted to evaluate the effect of an educational intervention on nursing personnel's knowledge and attitudes regarding the use of three integrative care techniques (hand massage, breathing techniques, and essential oils) with hospice and palliative care patients in an acute care setting. Data on knowledge and attitudes were collected pre- and postintervention.
RESULTS: Following the intervention, improvements in nursing personnel's attitudes and knowledge toward the use of the three techniques were found.
CONCLUSION: Results of this study suggest that education of nursing personnel may positively influence knowledge and attitudes toward providing hand massage, breathing techniques, and essential oil for end of life patients.
Introduction: Including palliative care (PC) in overloaded medical curricula is a challenge, especially where there is a lack of PC specialists. We hypothesised that non-specialised rotations could provide meaningful PC learning when there are enough clinical experiences, with adequate feedback.
Objective: Observe the effects of including PC topics in non-specialised placements for undergraduate medical students in two different medical schools.
Design: Observational prospective study.
Setting: Medical schools in Brazil.
Participants: 134 sixth-year medical students of two medical schools.
Methods: This was a longitudinal study that observed the development of Self-efficacy in Palliative Care (SEPC) and Thanatophobia (TS) in sixth-year medical students in different non-specialised clinical rotations in two Brazilian medical schools (MS1 and MS2). We enrolled 78 students in MS1 during the Emergency and Critical Care rotation and 56 students in MS2 during the rotation in Anaesthesiology. Both schools provide PC discussions with different learning environment and approaches.
Primary outcomes: SEPC and TS Scales were used to assess students at the beginning and the end of the rotations.
Results: In both schools’ students had an increase in SEPC and a decrease in TS scores.
Conclusion: Non-specialised rotations that consider PC competencies as core aspects of being a doctor can be effective to develop SEPC and decrease TS levels.
Purpose: This multi-component educational intervention was aimed at General Internal Medicine residents’ perceived self-efficacy in providing end of life care. This study also measured the uptake of the Comfort Measures Order Set.
Methods: This non-randomized study was conducted over nine 4-week rotations on one General Internal Medicine ward. The intervention consisted of: 1) a didactic module, 2) presence of the Palliative Care Consult Team at General Internal Medicine rounds and, 3) provision of end of life care educational materials. Twenty learners completed a pre/post Self-Efficacy in Palliative Care Scale.
Data/Results: Data revealed improved self-efficacy ratings on the overall scale, and on all three subscales of the Self-Efficacy in Palliative Care Scale. The Comfort Measures Order Set was implemented in 62% of patient deaths in the intervention group, and 51% of patient deaths in the control group, demonstrating no statistical difference between these groups.
Conclusion: The uptake of the order set in both the intervention and control groups demonstrated utility in providing a clinical framework for delivering end of life care and highlighted the need for on-going education and enhancement of clinicians' self-efficacy in end of life care.
CONTEXT: The palliative medicine workforce lacks racial diversity with <5% of specialty Hospice and Palliative Medicine (HPM) fellows identifying as Black(1). Little is known about Black trainees' exposure to palliative care during their medical education.
OBJECTIVES: To describe palliative care training for Black students during medical school, residency, and fellowship training.
METHODS: We conducted a cross-sectional descriptive study employing internet searches and phone communication in September 2019. We evaluated 24 medical schools in 3 pre-determined categories: historically black colleges and universities (HBCUs, N=4) and non-underrepresented minority-serving institutions with the highest (N=10) and lowest (N=10) percentage of Black medical students. Training opportunities were determined based on the presence of a course, clerkship or rotation in the medical school and residency curricula, a specialty HPM fellowship program, and specialty palliative care consult service at affiliated teaching hospitals.
RESULTS: None of the four HBCUs with a medical school offered a palliative care course or clerkship, rotation during residency, or specialty HPM fellowship program. Three of four HBCUs were affiliated with a hospital that had a palliative care consult service. Institutions with the highest Black enrollment were less likely to offer palliative care rotations during internal medicine (p= 0.046) or family medicine (p= 0.019) residency training than those with the lowest Black enrollment.
CONCLUSION: Residents at schools with the highest Black medical student enrollment lack access to palliative care training opportunities. Efforts to reduce health disparities and underrepresentation in palliative care must begin with providing palliative-focused training to physicians from underrepresented minority backgrounds.
BACKGROUND: The linguistic and cultural diversity found in European societies creates specific challenges to palliative care clinicians. Patients' heterogeneous habits, beliefs and social situations, and in many cases language barriers, add complexity to clinicians' work. Cross-cultural teaching helps palliative care specialists deal with issues that arise from such diversity. This study aimed to provide interested educators and decision makers with ideas for how to implement cross-cultural training in palliative care.
METHODS: We conducted four focus groups in French- and Italian-speaking Switzerland. All groups consisted of a mix of experts in palliative care and/or cross-cultural teaching. The interdisciplinary research team submitted the data for thematic content analysis.
RESULTS: Focus-group participants saw a clear need for courses addressing cross-cultural issues in end-of-life care, including in medical disciplines outside of palliative care (e.g. geriatrics, oncology, intensive care). We found that these courses should be embedded in existing training offerings and should appear at all stages of curricula for end-of-life specialists. Two trends emerged related to course content. One focuses on clinicians' acquisition of cultural expertise and tools allowing them to deal with complex situations on their own; the other stresses the importance of clinicians' reflections and learning to collaborate with other professionals in complex situations. These trends evoke recent debates in the literature: the quest for expertise and tools is related to traditional twentieth century work on cross-cultural competence, whereas reflection and collaboration are central to more recent research that promotes cultural sensitivity and humility in clinicians.
CONCLUSION: This study offers new insights into cross-cultural courses in palliative and end-of-life care. Basic knowledge on culture in medicine, variable practices related to death and dying, communication techniques, self-reflection on cultural references and aptitude for interprofessional collaboration are central to preparing clinicians in end-of-life settings to work with linguistically and culturally diverse patients.
BACKGROUND: The medical student experience of a clinical elective in palliative care (PC) remains understudied. Reflective narrative interventions can help students hone narrative competency skills, make sense of their clinical experiences and shed light on their perception of the rotation.
OBJECTIVES: To evaluate medical student written reflections after a PC clinical elective.
DESIGN: Students were asked to write a short reflective essay after PC clinical electives using open-ended writing prompts.
SETTING: Essays were collected from third and fourth-year medical students after completion of a PC elective at three geographically diverse academic medical centers in the United States.
MEASUREMENTS: Essays were coded for themes using a conventional content qualitative method of analysis.
RESULTS: Thirty-four essays were analyzed and four major themes emerged: reflection on the mission of medicine or motivation for being in medicine, reflection on professional skills or lessons learned, reflection on patient's experience and personal responses to PC rotation. Sub-themes were also identified.
CONCLUSIONS: Themes underscore the utility of the PC clinical elective as a meaningful experience that imparts useful skills, builds empathy, reminds students of their own motivations for being in medicine and serves as a catalyst for reflection on their own lives and relationships with their patients. Awareness of medical students' personal and emotional responses to a PC elective can help inform educators as they support their students and provide opportunities for reflection and education.
Kidney palliative care is a growing subspecialty of clinical practice, education, and research in nephrology. It is an essential aspect of care for patients across the continuum of advanced kidney disease who have high symptom burden, multidimensional communication needs, and limited life expectancy. Training in kidney palliative care can occur in a variety of ways, from didactic curricula and clinical experiences embedded in nephrology fellowship training to the pursuit of additional dedicated fellowship training in palliative care. At this time, a minority of nephrologists pursue formal fellowship training in specialty palliative care. This article will discuss opportunities and challenges in building a skilled workforce that will address the palliative needs of patients living with advanced kidney disease.
OBJECTIVES: The aim was to review evidence from all randomized controlled trials (RCTs) using palliative care education or staff training as an intervention to improve nursing home residents' quality of life (QOL) or quality of dying (QOD) or to reduce burdensome hospitalizations.
DESIGN: A systematic review with a narrative summary.
SETTING AND PARTICIPANTS: Residents in nursing homes and other long-term care facilities.
METHODS: We searched MEDLINE, CINAHL, PsycINFO, the Cochrane Library, Scopus, and Google Scholar, references of known articles, previous reviews, and recent volumes of key journals. RCTs were included in the review. Methodologic quality was assessed.
RESULTS: The search yielded 932 articles after removing the duplicates. Of them, 16 cluster RCTs fulfilled inclusion criteria for analysis. There was a great variety in the interventions with respect to learning methods, intensity, complexity, and length of staff training. Most interventions featured other elements besides staff training. In the 6 high-quality trials, only 1 showed a reduction in hospitalizations, whereas among 6 moderate-quality trials 2 suggested a reduction in hospitalizations. None of the high-quality trials showed effects on residents' QOL or QOD. Staff reported an improved QOD in 1 moderate-quality trial.
CONCLUSIONS AND IMPLICATIONS: Irrespective of the means of staff training, there were surprisingly few effects of education on residents' QOL, QOD, or burdensome hospitalizations. Further studies are needed to explore the reasons behind these findings.
Nurses play a central role in delivering palliative care, given their influence on the quality of care provided (Montgomery, Sawin, & Hendricks-Ferguson, 2016). They are professionals of choice when it comes to assessing disease symptoms or psychological distress, ensuring symptoms are managed effectively, as well as accompanying patients and families through the decision-making process regarding both adult and pediatric care (Contro, Larson, Scofield, Sourkes, & Cohen, 2004). Optimal palliative care practices can prevent or alleviate the suffering of patients of all ages at the end of life, particularly if the care includes the assessment of symptoms and provides the patient and his or her family with psychological and social support (Qaseem et al., 2008). Although the majority of patients receiving palliative care are adults, more than 4,000 children in Canada have an incurable disease for which they will require quality palliative care (Widger, Cadell, Davies, Siden, & Steele, 2012). However, a number of studies carried out with nurses have revealed that they experience anxiety with regard to the pediatric palliative care (PPC) they deliver (Mullen, Reynolds, & Larson, 2015) and difficulties communicating with families of patients (Montgomery et al., 2017), as well as managing their emotions when they attend to a child who is at the end of life (Roberts & Boyle, 2005). Based on the first hypothesis suggested by Contro et al. (2004), such behaviour can be explained by a lack of knowledge regarding PPC.
Depuis plusieurs décennies, de nombreux rapports insistent sur la nécessité de diffuser les soins palliatifs en formant les étudiants en médecine à cette pratique. Dans ce contexte, l’évaluation des dispositifs pédagogiques est un impératif. Une recherche qualitative est réalisée auprès de 18 internes en médecine ayant effectué un stage de 6 mois dans une équipe de soins palliatifs, fixe ou mobile. Cette étude exploratoire vise à recueillir le retour qu’ils font sur leurs vécus lors du stage, les compétences qu’ils ont acquises, leurs appréciations sur les modalités pédagogiques. Après analyse des entretiens, cinq thématiques sont identifiées. Les internes décrivent une déstabilisation initiale en début de stage. Ils relatent un renforcement de leurs compétences professionnelles avec l’apprentissage d’un meilleur rapport à leurs émotions. Ils font le constat que de nombreuses compétences sont transférables dans leur spécialité, mais que, bien souvent, la compétence délibérative ne peut être vécue qu’individuellement. Ils mentionnent une expérience de questionnement et de réflexivité sur leur parcours professionnel et personnel. Ils soulignent le rôle favorable de l’accompagnement pédagogique. Si l’apport d’un stage en équipe de soins palliatifs apparaît manifeste, il importe que les référents pédagogiques mènent une réflexion éthique afin de bien comprendre les fondements de la clinique palliative mais aussi les décalages, les tensions, voire les paradoxes vis-à-vis du référentiel médical actuel.
Background: According to the Latin America Association for palliative care, Brazil offers only 0.48 palliative care services per 1 million inhabitants. In 2012, no accredited physicians were working in palliative care, while only 1.1% of medical schools included palliative care education in their undergraduate curricula. As a reflection of the current scenario, little research about end-of-life care has been published so that studies addressing this subject in the Brazilian setting are crucial.
Methods: A cross-sectional study study conducted with students applying for the medical residency of the Federal University of São Paulo were invited to voluntarily participate in an anonymous and self-administered questionnaire survey. The latter included demographic information, attitudes, prior training in end-of-life care, prior end-of-life care experience, the 20-item Palliative Care Knowledge Test (PCKT) and a consent term.
Results: Of the 3086 subjects applying for residency, 2349 (76%) answered the survey, 2225 were eligible for analysis while 124 were excluded due to incomplete data. Although the majority (99,2%) thought it was important to have palliative care education in the medical curriculum, less than half of them (46,2%) reported having received no education on palliative care. The overall performance in the PCKT was poor, with a mean score of 10,79 (± 3). While philosophical questions were correctly answered (81,8% of correct answers), most participants lacked knowledge in symptom control (50,7% for pain, 57,3% for dyspnea, 52,2% for psychiatric problems and 43,4% for gastrointestinal problems). Doctors that had already concluded a prior residency program and the ones that had prior experience with terminal patients performed better in the PCKT (p < 0,001). The high-performance group (more than 50% of correct answers) had received more training in end-of-life care, showed more interest in learning more about the subject, had a better sense of preparedness, as well as a higher percentage of experience in caring for terminal patients (p < 0,001).
Conclusions: Our study showed that Brazilian physicians lack not only the knowledge, but also training in end-of-life medicine. Important factors to better knowledge in end-of-life care were prior training, previous contact with dying patients and prior medical residency. Corroborating the literature, for this group, training showed to be a key factor in overall in this area of knowledge. Therefore, Brazilian medical schools and residency programs should focus on improving palliative training, especially those involving contact with dying patients.
Background: There are no data on the provision of palliative nursing care in Egyptian adult intensive care units (ICUs). The Palliative and End-Of-Life (PEOL) Care Index is reliable and content valid; however, its construct and criterion validities have not been examined.
Aims and objectives: First, to assess palliative care education, practice, and perceived competence among adult ICU nurses in Egypt. Second, to explore factors related to palliative care nursing practice and perceived competence. Third, to assess the construct and criterion validities of the PEOL Care Index.
Design: A cross-sectional survey.
Methods: Nurse managers and staff nurses in 33 adult ICUs completed self-administered questionnaires. The questionnaires assessed nurses' palliative care practice and perceived competence. A multilevel regression analysis was used to determine the best predictors of palliative care practice and perceived competence. Theory evidence construct validity and predictive criterion validity of the PEOL Care Index were examined.
Results: Thirty-three nurse managers and 403 staff nurses participated in the study—response rate = 100% and 72.5%, respectively. On a 0-100 scale, the mean scores of undergraduate education, practice, and perceived competence were 54.0 ± 18.7, 49.7 ± 18.1, and 54.5 ± 17.0, respectively. Palliative care practice was significantly related to receiving in-service training on palliative care or end-of-life care (regression coefficients: 3.39), higher job satisfaction (0.97), and higher organizational support (1.85). Palliative care perceived competence was significantly related to older nurses' age (0.20), higher job satisfaction (0.97), and higher palliative care undergraduate education (0.63).
Conclusions: Palliative care education, practice, and perceived competence among adult ICU nurses in Egypt are inadequate, especially in terms of spiritual and cultural care. The PEOL Care Index is construct and criterion valid.
Relevance to clinical practice: Palliative care education should begin in nursing schools and extend through clinical in-services. Guidelines should be developed to maximize staff collaboration and the utilization of chaplains in ICUs.
Introduction: Despite growing recognition of pediatric palliative care's importance, training in palliative care communication remains a gap in medical education. Graduating medical students frequently feel unprepared to initiate or facilitate goals of care conversations with their patients, particularly in pediatrics.
Methods: We created a 3-hour session featuring an introductory lecture on pediatric palliative care, communication drills on responding to emotion, and small-group case-based discussions utilizing role-play, targeting fourth-year medical students as the primary learners. Senior residents were also given the opportunity to develop skills by role-playing the patient parent and cofacilitating case discussions alongside palliative care faculty. Students evaluated session utility and their own confidence through pre- and postsession surveys using a 5-point Likert scale (1 = strongly disagree, 5 = strongly agree).
Results: Twenty-six students were included in the analysis over 3 years. All agreed that the session was useful (M = 4.9). Students showed significant improvement in confidence in explaining pediatric palliative care (presession M = 3.2, postsession M = 4.1, p < .001), understanding the family experience (presession M = 2.7, postsession M = 4.1, p < .001), and eliciting goals and values from families whose children face serious illnesses (presession M = 3.1, postsession M = 4.1, p < .001). Pediatric resident cofacilitators also felt the session benefited their own teaching and communication skills.
Discussion: This 3-hour interactive session on pediatric palliative care utilizing communication drills and role-play was effective in improving fourth-year medical students' confidence in communicating with families of children facing life-threatening illnesses.
With an increasingly ageing population there will be a rising demand for palliative care, including from older migrants and ethnic minorities. While many (future) physicians are unfamiliar with specific needs of older migrants and ethnic minorities regarding care and communication in palliative care, this may be challenging for them to deal with. Moreover, even many medical teachers also feel unprepared to teach palliative care and culturally sensitive communication to students. In order to support medical teachers, we suggest twelve tips to teach culturally sensitive palliative care to guide the development and implementation of teaching this topic to medical students. Drawn from literature and our own experiences as teachers, these twelve tips provide practical guidance to both teachers and curriculum designers when designing and implementing education about culturally sensitive palliative care.
Self-efficacy and confidence levels among newly graduated nurses who participated in an end-of-life simulation were compared with nurses who had been practicing for no more than a year but had not participated in an end-of-life simulation. The study included a pretest-and-posttest evaluation of an end-of-life simulation intervention during a new graduate residency program among newly graduated nurses to improve self-efficacy and confidence with end-of-life care. Nurses who had been in practice for no more than a year but had not been exposed to an end-of-life simulation intervention were also surveyed. The Palliative Care Evaluation Tool Kit was adapted and used for this project. The 2 groups of nurses were compared in terms of self-efficacy and confidence levels regarding end-of-life care. An end-of-life simulation intervention was successful in improving self-efficacy and confidence levels among newly graduated nurses, in regard to views about end of life and death and dying compared with the nurses who did not receive the end-of-life simulation intervention. The results of this study have implications for both schools of nursing and hospital training programs.
The current COVID-19 pandemic has necessitated the redeployment of NHS staff to acute-facing specialties, meaning that care of dying people is being provided by those who may not have much experience in this area. This report details how a plan, do, study, act (PDSA) approach was taken to implementing improved, standardised multidisciplinary documentation of individualised care and review for people who are in the last hours or days of life, both before and during the COVID-19 pandemic. The documentation and training produced is subject to ongoing review via the specialist palliative care team's continuously updated hospital deaths dashboard, which evaluates the care of patients who have died in the trust. We hope that sharing the experiences and outcomes of this process will help other trusts to develop their own pathways and improve the care of dying people through this difficult time and beyond.
Education leaders in Hospice and Palliative Medicine (HPM) have long acknowledged the challenge of fellow performance assessment and the need for HPM specific fellow assessment tools. In 2010, and in alignment with the Accreditation Council for Graduate Medical Education's (ACGME) directive toward competency-based medical education, the national HPM Competencies Workgroup curated a set of assessment tools, the HPM Toolkit of Assessment
Methods. The Toolkit has been a resource for HPM fellowship directors in evolving practical, multi-faceted fellow assessment strategies. Now, as AAHPM plans for a national workgroup in 2020 to define current HPM fellow assessment methods and to propose strategies to strengthen and standardize future assessment, the Toolkit provides a strong base from which to launch. However, the field learned important lessons from the 2010 Workgroup about the consensus process, gaps in areas of assessment, opportunities to address gaps with new or adapted tools, and limitations in implementing the Toolkit over time in terms of tracking, accessibility, and dissemination. This paper describes the development of the Toolkit, including recommended tools and methods for assessment within each ACGME competency domain, and links the lessons learned to recommendations for the 2020 workgroup to consider in creating the next HPM assessment strategy and toolkit. Effective implementation will be crucial in supporting fellows to reach independent practice, which will further strengthen the field and workforce to provide the highest quality patient and family-centered care in serious illness. This will require an inspired, committed effort from the HPM community, which we enthusiastically anticipate.
Background: The growing trend in providing palliative care and end-of-life services has dictated that healthcare providers be adequately trained to care for people with serious illnesses, such as multiple sclerosis (MS) and neuromyelitis optica spectrum disorder (NMOSD). These progressive inflammatory diseases lead to physical, cognitive and emotional deficits and have exceptionally high care demands leading to high levels of distress. Because the impact on the delivery of patient care is influenced by the specialists' knowledge and comfort discussing end-of-life issues, it is concerning that interventions to address unmet palliative care needs in MS and NMOSD rarely include clinician-patient dyads.
Objectives: To evaluate the neurology clinicians' knowledge and level of comfort discussing palliative care and end-of-life issues.
Design: A cross sectional survey was conducted. The statistical analyses included frequencies, chi square statistics and logistic regression.
Setting/Subjects: 414 MS specialists answered an online anonymous survey. The survey was conducted using email distributions to MS professionals through the Consortium of MS Centers (CMSC), the International Organization of MS Nurses (IOMSN) and the UK Nurses' MS Organization.
Measurement: The "End of Life Professional Caregiver Survey" (EPCS) was used to collect data.
Results: The majority of the multidisciplinary professionals were female, white, nurses, and older than 40 years of age. 41% had their own advance directives and 57.6% had end-of-life basic training. There was a statistically significant association between end-of-life training or having advance directives and comfort discussing palliative care and end of life issues. Professionals that had basic end-of-life training and their own advance directives had higher comfort discussing code status, specific end-of-life issues, and advance directive planning.
Conclusions: Basic end-of-life training and having advance directives among MS professionals were associated with better communication of palliative care and end-of-life domains with patients and their care partners.
Les décès sont potentiellement fréquents à l’hôpital et notamment en gériatrie. Les internes en médecine se déclarent en difficulté pour assurer un accompagnement médical de qualité dans les situations de fin de vie. Afin de les soutenir dans leur formation clinique nous rapportons l’expérience d’ateliers d’expression mensuels, neutres, confidentiels pour leur permettre d’adapter leur pratique et prévenir les risques psychosociaux inhérents à la confrontation avec la mort.
Cet ouvrage se compose d'une cinquantaine de fiches thématiques sur les soins palliatifs afin d'accompagner de façon expérimentée la fin de vie des patients : les principes éthiques, les acteurs, le temps, les moyens, l'expérience pour le patient et pour les équipes, les dispositifs singuliers, entre autres.