Introduction: Pediatric residents are faced with ethical dilemmas in beginning- and end-of-life situations throughout their training. These situations are innately challenging, yet despite recommendations that residents receive training in ethics and end-of-life domains, they continue to report the need for additional training. To address these concerns, we developed an interactive and reflective palliative care and medical ethics curriculum including sessions focusing on ethical dilemmas at the beginning and end of life.
Methods: This module includes a trio of case-based, small-group discussions on artificial nutrition and hydration, futility, and ethical considerations in neonatology. Content was developed based on a needs assessment, input from local experts, and previously published material. Trainees completed assessments of comfort and understanding before and after each session.
Results: The module was attended and assessed by an average of 27 trainees per session, including residents and medical students. Knowledge of ethical considerations improved after individual sessions, with 86% of trainees reporting understanding ethical considerations involved in the decision to withdraw or withhold medically provided nutrition and hydration and 67% of trainees reporting understanding the use of the term futility. Trainee comfort in providing counseling or recommendations regarding specific ethical issues demonstrated a trend toward improvement but did not reach statistical significance.
Discussion: We successfully implemented this innovative module, which increased trainees' comfort with end-of-life care and ethical conflicts. Future studies should focus on the trainees' ability to implement these skills in clinical practice.
"Kipal, le jeu du qui quoi comment en soins palliatifs" est un outil ludopédagogique élaboré par une infirmière et un médecin membres d’une équipe mobile de soins palliatifs au centre hospitalier de Vienne. Grâce à la création de cas patients fictifs et évolutifs au cours du jeu, les soignants participants peuvent appréhender des thèmes variés concernant les soins palliatifs de façon interactive. Les bénéfices attendus sont, une implication des apprenants devenant acteurs de leur formation, la dédramatisation du thème des soins palliatifs, la définition d’une démarche palliative et la découverte de la variété des prises en soin par la richesse des scénarios possibles. Pour cela, le jeu propose 16 situations cliniques brèves, issues de diverses spécialités, 46 cartes dites "évènement" (clinique, psychologique, social ou familial) et 62 cartes "suggestion" (ressources humaines et techniques disponibles) qui pourront être associées à l’infini à chaque partie. Cet outil est réservé aux professionnels des soins palliatifs lors de formations destinées à des soignants non spécialisés, mais exerçant auprès de personnes nécessitant des soins palliatifs. En perspective, des extensions pourront être développées pour s’adapter à un public plus large (pédiatrie, domicile). Soutenu par le Fonds pour les soins palliatifs et approuvé par la Société française d’accompagnement et de soins palliatifs (SFAP), 250 jeux Kipal ont été attribués lors du congrès francophone de soins palliatifs organisé par la SFAP et la Fédération francophone internationale de soins palliatifs en 2019.
As the population ages, the number of careers that intersect with aging is expected to grow. However, many young people lack an interest in working with aging populations. As previous work has shown, though, students' interest in aging careers may be stimulated by coursework and experiential activities related to aging. Despite being a normative developmental process, anxiety about death and dying may be particular barriers to students developing interest in aging, and these topics may be particularly difficult subjects to teach in the college classroom. Here, strategies and activities for teaching the end of life are offered.
OBJECTIVE: To describe how and when surgery residents provided primary palliative care and engaged specialty palliative care services.
DESIGN: Phase I consisted of a previously validated survey instrument supplemented with additional questions. We then conducted semistructured interviews with a subset of the survey respondents (Phase II). Using thematic analysis, we characterized surgery residents' perceptions of palliative care delivery among surgical patients.
SETTING: General surgery residency programs across the state of Michigan.
PARTICIPANTS: General surgery residents across the state of Michigan. All residents in participating programs were invited to complete the survey in Phase I. Phase II consisted of a subset of the survey respondents who underwent semistructured interviews. Interview respondents were sampled to reflect the overall surveyed group.
RESULTS: Among 119 survey respondents (response rate 70%), all had encountered a palliative care specialist but only 58.8% had been taught when to consult or to refer to palliative care. Survey respondents reported on a multitude of barriers within the clinician, patient and family, and systemic domains. Interviews expanded on survey findings and 4 influential factors of palliative care delivery emerged: (1) Resident Education and Training; (2) Resident Attitudes Toward Palliative Care; (3) Knowledge of Palliative Care; and (4) Training within a Surgical Culture.
CONCLUSIONS: This study reveals how surgery resident training and experiences impact palliative and end-of-life care for surgical patients at teaching institutions. Knowledge of how and when residents are providing primary palliative care and engaging with palliative care services will inform future knowledge and behavioral interventions for trainees who often provide care for patients nearing the end of life.
OBJECTIVE: To characterize how pediatric resident self-evaluation compares to standardized patient evaluations in simulated child death disclosure scenarios.
STUDY DESIGN: This was a prospective, observational, mixed-methods study in which 18 PGY-2 pediatric residents delivered the news of a death of a child to a trained standardized patient (SP) couple. The SPs evaluated residents via a quantitative global rating (1 to 3 scale) and via qualitative comments. Following the training, the residents completed self-assessments consisting of a global rating, qualitative comments, and their confidence related to five death disclosure skills.
RESULTS: Agreement between SPs and resident ratings was poor; resident scores were compared to each of their two SP evaluators yielding Kappa coefficients of -0.23 (95% CI = -0.60 to -0.07) and –0.30 (95% CI = -0.70 to –0.04). Residents uniformly rated themselves as less capable in their communication skills than SPs did. Residents reported significant increases in their confidence in discussing autopsy and organ donation. Major themes determined from the qualitative comments from SPs included non-verbal communication, verbal communication, attunement to parents, and management of next steps. Residents’ comments mirrored these themes with the exception of the absence of non-verbal communication.
CONCLUSIONS: Pediatric residents underestimated their abilities in a self-assessment of their performance in a SP death disclosure scenario, demonstrating the importance of external feedback, particularly from SPs themselves. Based on SP feedback, future death disclosure trainings should emphasize non-verbal communication skills and specific behaviors that convey effective attunement to families.
Les projets de vie de l’enfant font partie intégrante des soins palliatifs. Dans un contexte d’avenir incertain, proposer un projet de scolarisation, c’est proposer un projet de continuité du lien social et un projet de vie bien réel. Notre expérience témoigne de la possibilité d’intégration en milieu scolaire d’une enfant en soins palliatifs, pour une pathologie avec un risque vital présent et une déformation faciale source de différence et de non intégration potentielle. Le dynamisme et la bienveillance de tous ont permis de recréer un lien essentiel, source de revalorisation pour l’enfant en soin palliatif, au-delà des différences.
BACKGROUND: With increased demand for palliative care (PC), the World Health Organisation (WHO) have called for PC teaching to be made routine. However, medical students report feeling unprepared in dealing with end-of-life care. Necessary benchmarking of the preparedness of clinicians to provide PC is required to identify where current training is sub-optimal and ensure future doctors are equipped to meet the needs of their patients. The aim of this study is to assess the utility of an electronic International Medical Education in Palliative Care (IMEP-e) assessment tool that examines the preparedness of clinicians to provide PC.
METHODS: A multi-phase pilot study. Phase 1: To transpose the Self-Efficacy Palliative Care Scale (SEPCs) and the Thanatophobia Scale (TS) to an electronic format and evaluate its utility. Phase 2: To assess the effects of PC teaching by comparing data from year three (Y3) and year five (Y5 - who have participated in PC placement) medical students. Scales: The 23 item SEPC and 7 item TS assess attitudes towards caring for dying patients.
RESULTS: Total questionnaires sent =360 (280 Y3, 80 Y5). Total response rate = 46.39%, n = 167 (127 Y3, 40 Y5). Completed data: n = 125 (95 Y3, 30 Y5). Analysis identified statistically significant differences (p < 0.001) between year groups across all subscales of the SEPC; communication skills (t = - 13.52), Pain and Treatment management (t = - 14.25) and multidisciplinary management (t = - 7.89). The TS shows a statistically significant increased positive attitudes (z = - 2.85 p < 0.005). From the focus group, three themes were identified from the qualitative feedback including university based teaching, hospice based teaching and utility of IMEP-e tool.
CONCLUSION: The IMEP-e tool is a viable and comparable method for collecting data on the preparedness to practice PC. A larger scale study is needed to determine and evaluate if, and how, preparing clinicians to work in PC has been adapted in to routine training.
BACKGROUND: Although palliative care is recognized as an important component of medical school curricula, the content and structure of education in the field is variable and often lacks outpatient exposure. We aimed to develop and implement a palliative care clinical elective for fourth-year medical students incorporating both inpatient and outpatient learning.
METHODS: Fourteen medical students participated in a palliative care elective which included 2 weeks on an inpatient consult service and 1 week of outpatient clinic and home hospice visits. The elective was evaluated using a focus group and previously validated surveys assessing self-rated competency and attitudes toward caring for palliative care patients. Data were analyzed using paired t tests to compare survey response means before and after the elective.
RESULTS: Of the 14 participating students, 7 completed both the pre- and postelective surveys. Significant improvements in self-rated competency were seen in pain and symptom management (P < .001), communication (P < .001), and advance care planning (P < .01). Survey results also showed improvement in attitudes toward caring for dying patients (P < .001), with lower scores at the end of the elective suggesting reduced emotional distress. Although the outpatient component was hypothesized to be a major benefit of the curriculum, qualitative data revealed the most highly valued component to be direct observation and feedback during inpatient time.
CONCLUSION: Given the highlighted importance of direct observation and feedback as a unique and powerful learning experience, future work should be targeted toward enhancing the quality and timeliness of feedback delivered by the palliative care interdisciplinary team.
PURPOSE: Spirituality and religion affect patient health. This topic is often not included in medical resident education. We aimed to evaluate resident knowledge, attitudes, and skill regarding spirituality, religion, and medicine and to develop, implement, and evaluate a curriculum to improve these measures.
METHODS: Internal medicine residents at a large, urban academic center were surveyed to determine their baseline knowledge, attitudes, and skill regarding spirituality and religion (37.4% response rate, n = 46/123). A lecture and discussion-based curriculum was implemented over 1 year, followed by another survey (41.4% response rate, n = 51/123); 2 statistic was used to compare pre- and postsurveys to evaluate the curriculum.
RESULTS: Baseline resident attitudes toward spirituality, religion, and medicine were high with most agreeing chaplains are valuable in patient care (93.5%) and that patient spiritual and religious beliefs can affect health (93.5%). Resident self-reported knowledge and skill were low with few knowing the training chaplains receive (4.3%) or reporting competence taking a spiritual history (15.2%). After the curriculum, resident self-reported knowledge increased regarding the role of chaplains (56.5%-80.4%, P = .011) and the training chaplains receive (4.3%-27.5%, P = .002). No significant postcurriculum change was seen in attitudes or skill.
CONCLUSIONS: Most internal medicine residents have positive attitudes toward spirituality, religion, and medicine. They do not have adequate knowledge or skill to care for patients in this area, however. Implementation of a curriculum in spirituality, religion, and medicine improved resident self-reported knowledge. Future work should focus on revising the curriculum to better improve resident knowledge and skill.
Context: Most children living and dying with serious illnesses experience high burden of distressing symptoms. Many seriously ill children and their families do not have access to subspecialist pediatric palliative care (PPC) services nor to clinicians trained in primary PPC. Lack of PPC education appears to be a significant barrier to PPC implementation.
Objectives: Description of the development and dissemination of Education in Palliative and End-of-Life Care (EPEC)-Pediatrics.
Methods: Funded through a US$1.6 million National Institutes of Health / National Cancer Institute grant 2010-2017, this 24-module curriculum was designed to teach primary palliative care. The target audience included interprofessional pediatric hematology/oncology providers and all other clinicians caring for seriously ill children.
Results: The curriculum is delivered in a combination of online learning and in-person, face-to-face sessions. Additionally, a one-day Professional Development Workshop (PDW) was developed to teach EPEC-Pediatrics graduates to teach future "Trainers," thus becoming "Master Facilitators". Between 2012-May 2019 a total of 867 EPEC-Pediatric Trainers and 75 Master Facilitators from 58 countries participated in 17 Become an EPEC-Pediatrics-Trainer conferences and three PDWs. The curriculum has also been adapted for large-scale dissemination across Canada and Latin-America, with translation to French and Spanish.
Participants: overwhelmingly report improvements in their PPC knowledge, attitudes, and skills, including teaching. Participants subsequently anticipated improvements in patient care for children with serious illness at their home institutions.
Conclusion: EPEC-Pediatrics has developed into the most comprehensive PPC curriculum. It is highly adaptable for local settings, became self-sustaining and six conferences are offered around the world in 2019.
BACKGROUND: Contemporary health policies call for consumers to be part of all aspects of service planning, implementation, delivery and evaluation. The extent to which consumers are part of the systemic decision-making levels of palliative care appears to vary between and within services and organisations.
AIM: The aim of this systematic review is to develop understandings about consumer and carer leadership in palliative care.
DESIGN: A systematic, narrative synthesis approach was adopted due to the heterogeneity of included studies. The review was registered on PROSPERO prospectively (PROSPERO 2018 CRD42018111625).
DATA SOURCES: PubMed, Scopus and PsycINFO were searched for all studies published in English specifically focusing on consumers' leadership in palliative care organisations and systems. Articles were appraised for quality using a modified JBI-QARI tool.
RESULTS: Eleven studies met the inclusion criteria and quality assessment. Consumers are currently involved in leadership of palliative care teaching, research and services. Findings highlight the benefits of consumer leadership in palliative care including more relevant, higher-quality services, teaching and research. Across the included studies, it was not clear the extent to which consumer leaders had influence in relation to setting agendas across the palliative care sector.
CONCLUSION: The findings suggest that more could be done to support consumer leadership within palliative care. Academics and clinicians might improve the relevance of their work if they are able to more meaningfully partner with consumers in systemic roles in palliative care.
BACKGROUND: Advance care planning (ACP) is an essential skill for clinicians, yet trainees feel inadequately prepared to conduct ACP discussions. Optimal teaching methods and timing are unknown.
AIM: We designed a curricular intervention to expose second-year medical students to the process of ACP, aiming to improve their ACP knowledge and confidence.
DESIGN: The intervention consisted of a case-based workshop facilitated by a physician experienced in ACP ("facilitated ACP workshop"), which was added to an existing multifaceted ACP curriculum (longitudinal senior mentor program including multiple visits with a volunteer older adult, completion of an electronic ACP learning module and reflective writing exercise). The control group received the existing ACP curriculum only, while the intervention group received the existing curriculum plus the facilitated ACP workshop. Both groups completed an ACP knowledge assessment and confidence survey at the conclusion of the curriculum.
SETTING/PARTICIPANTS: Two consecutive classes of second year medical students, single academic hospital.
RESULTS: No statistically significant differences in ACP knowledge or confidence were seen post-intervention. Overall confidence with ACP tasks remained relatively low despite a multifaceted ACP curriculum.
CONCLUSIONS: Future studies should investigate longitudinal, experiential ACP learning, and seek to optimize ACP teaching strategies and timing.
This study investigates medical trainees' experiences with dying and death, by means of semistructured interviews. Nine medical students and nine residents reported a total of 114 experiences. The great majority of these experiences took place during the final year of medical school. The authors identified the latent characteristics, which illustrate an in-depth understanding of the significance of the described experiences. Three main themes emerged: circumstances of death, personal relationship, and one's own role. The age of the dying person, the extent of suffering, time frame and setting, and the patients' behaviors were factors that influence the perceptions of the experiences. The interviewees reported powerful emotional consternation by the patients' deaths with whom they had developed a close relationship. Failure, helplessness, and guilt were negatively associated perceptions of one's own role. This study illustrates the tension between emotional concern and professional detachment. It highlights the continuing existence of a physician image, in which control represents the key issue.
Cancer is a leading cause of death in Australia and is also the leading cause of disease burden as survivorship continues to improve. Given the prevalence of oncology patients in the community, it is likely to be a condition encountered by every junior doctor. Despite this oncology and in conjunction with that, palliative care has not been a core component of medical curriculum until recently. This means that the junior doctor experience is often complicated by lack of knowledge, poor understanding of the disease process, treatment options and complications and therefore makes managing these patients complicated and often an uncessarily stressful process. This reflective article explores current issues in cancer education, a reflection and comparison between pre- and post-internship experience and offers some potential solutions to these issues.
OBJECTIVE: The purpose of this study was to demonstrate effectiveness of an educational training workshop using role-playing to teach medical students in Botswana to deliver bad news.
METHOD: A 3-hour small group workshop for University of Botswana medical students rotating at the Princess Marina Hospital in Gaborone was developed. The curriculum included an overview of communication basics and introduction of the validated (SPIKES) protocol for breaking bad news. Education strategies included didactic lecture, handouts, role-playing cases, and open forum discussion. Pre- and posttraining surveys assessed prior exposure and approach to breaking bad news using multiple-choice questions and perception of skill about breaking bad news using a 5-point Likert scale. An objective structured clinical examination (OSCE) with a standardized breaking bad news skills assessment was conducted; scores compared two medical student classes before and after the workshop was implemented.Result: Forty-two medical students attended the workshop and 83% (35/42) completed the survey. Medical students reported exposure to delivering bad news on average 6.9 (SD = 13.7) times monthly, with 71% (25/35) having delivered bad news themselves without supervision. Self-perceived skill and confidence increased from 23% (8/35) to 86% (30/35) of those who reported feeling "good" or "very good" with their ability to break bad news after the workshop. Feedback after the workshop demonstrated that 100% found the SPIKES approach helpful and planned to use it in clinical practice, found role-playing helpful, and requested more sessions. Competency for delivering bad news increased from a mean score of 14/25 (56%, SD = 3.3) at baseline to 18/25 (72%, SD = 3.6) after the workshop (p = 0.0002). Significance of results: This workshop was effective in increasing medical student skill and confidence in delivering bad news. Standardized role-playing communication workshops integrated into medical school curricula could be a low-cost, effective, and easily implementable strategy to improve communication skills of doctors.
INTRODUCTION: Denmark has been ranked low regarding the extent of teaching in palliative care (PC) at medical schools although the Danish Health Authority recommends that all doctors have basic knowledge of PC. The aim of this study was to investigate the contents of and time spent on teaching in PC at the four Danish medical schools and to compare results with recommendations from the European Association of Palliative Care (EAPC).
METHODS: Data were collected by examining university curricula, course catalogues, etc., using search words based on recommendations from the Palliative Education Assessment Tool and by a questionnaire survey among the university employees responsible for semesters or courses in Danish medical schools.
RESULTS: Teaching in palliative medicine at Danish medical schools is generally sparse and mainly deals with pain management and general aspects of PC. Compared to European recommendations, teaching in, e.g., ethics, spirituality, teamwork and self-reflection is lacking. Furthermore, PC training does not reach the recommended minimum of 40 hours, and examinations in PC are not held. As from the autumn of 2017, the University of Southern Denmark has offered a course that expands teaching in PC and thereby improves compliance with EAPC recommendations; the remaining three medical schools do not, to our knowledge, have any specific plans to increase the extent of teaching activities in palliative medicine.
CONCLUSIONS: Teaching in palliative medicine is sparse at all four medical schools in Denmark and should be strengthened to meet Danish as well as European recommendations.
FUNDING: No funding was used for this study.
TRIAL REGISTRATION: not relevant.
BACKGROUND: In Europe in recent decades, university teaching of palliative medicine (PM) has evolved. In some countries it has been introduced as a compulsory subject in all medical schools, but in a majority of countries it remains an isolated subject at few universities.
OBJECTIVE: To explore how PM has been introduced into the curricula and how it is currently being taught at different European universities.
METHOD: Case study method using face-to-face semistructured interviews with experienced PM professors, comparing how they have developed PM undergraduate programs at their universities.
RESULTS: An intentional sample of eight university professors from Spain, France, UK, Italy, Hungary, Sweden, Germany, and Poland was chosen. The introduction of PM in the universities depends on the existence of a favorable social and political context in relation to palliative care and the initiative of pioneers, trusted by students, to push this education forward. A PM curriculum frequently starts as an optional subject and becomes mandatory in a short period. In the reported universities, PM uses a wide variety of teaching methods, such as lectures, workshops, role-plays, and discussions. PM assessment included tests, discussions, reflections, portfolios, and research works. According to respondents' opinions, lack of recognition, funding, and accredited teachers, along with competition from other curricula, are the main barriers for palliative medicine teaching development at universities.
CONCLUSION: Diverse paths and tools have been identified for PM teaching in Europe. The described cases may shed light on other medical schools to develop PM curricula.
Dans les soins palliatifs, la scolarisation des enfants peut et doit être envisagée comme ancrage à la réalité. Elle permet une mise à distance de la maladie. Pratiquée en classe ou au chevet, à l’hôpital ou au domicile, elle est souvent dispensée par des enseignants spécialisés. Ceux-ci sont formés pour permettre à l’enfant en fin de vie de s’inscrire dans un projet personnel primordial comme celui d’obtenir un examen, d’apprendre à lire ou à écrire, de laisser une trace artistique ou autre. Le SAPAD (service d’assistance pédagogique à domicile) prend toute son importance dans l’organisation du suivi pédagogique à domicile. La scolarité fait partie intégrante du projet de soin et nécessite de travailler en équipe de manière pluridisciplinaire.