Objectives: To map current practice regarding discussions around resuscitation across England and Scotland in patients with cancer admitted acutely to hospital and to demonstrate the value of medical students in rapidly collecting national audit data.
Methods: Collaborators from the Macmillan medical student network collected data from 251 patient encounters across eight hospitals in England and Scotland. Data were collected to identify whether discussion regarding resuscitation was documented as having taken place during inpatient admission to acute oncology. As an audit standard, it was expected that all patients should be invited to discuss resuscitation within 24 hr of admission.
Results: Resuscitation discussions were had in 43.1% of admissions and of these 64.0% were within 24 hr; 27.6% of all admissions. 6.5% of patients had a “do not attempt resuscitation” order prior to admission with a difference noted between patients receiving palliative and curative treatment (8.5% and 0.39%, respectively, p < .05). Discussions regarding escalation of care took place in only 29.3% of admissions.
Conclusions: These data highlight deficiencies in the number of discussions regarding resuscitation that are being conducted with cancer patients that become acutely unwell. It also demonstrates the value of medical student collaboration in rapidly collecting national audit data.
Caring for dying patients is often a new experience for ICU residents. End-of-life and palliative training in medical schools is lacking. Many residents experience troublesome emotions during residency. Literature establishes that residents show lower well-being scores than similar populations. To make emotional wellness a priority for residents, monthly mandatory Palliative Care Rounds (PCR) were established in the ICU. The role of the Palliative Care Social Worker (PCSW) is central in planning and implementing PCR. Social workers have unique skills well-suited to this type of activity in an acute care setting. Residents present cases and the PCSW facilitates discussion to explore complex emotions helping residents process their feelings. Forty-five residents responded to a seven-item questionnaire, out of 70 potential resident respondents (64% response rate). Only 60% said they learned about end-of-life and its emotional aspects in medical school. Ninety-eight percent reported the PCR helped them be more aware of their feelings, and would recommend it to colleagues. Ninety-five percent said PCR are important for interns and residents to help them grow professionally and become better clinicians. Through the process of dissecting their emotions, PCR allows for personal and professional growth that improves residents’ ability to become empathic providers.
As nearly all doctors deal with patients requiring palliative care, it is imperative that palliative care education starts early. This study aimed to validate a national, palliative care competency framework for undergraduate medical curricula. We conducted a Delphi study with five groups of stakeholders (palliative care experts, physicians, nurses, curriculum coordinators, and junior doctors), inviting them to rate a competency list. The list was organized around six key competencies. For each competency, participants indicated the level to which students should have mastered the skill at the end of undergraduate training. Stability was reached after two rating rounds (N = 82 round 1, N = 54 round 2). The results showed high levels of agreement within and between stakeholder groups. Participants agreed that theoretical knowledge is not enough: Students must practice palliative care competencies, albeit to varying degrees. Overall, communication and personal development and well-being scored the highest: Junior doctors should be able to perform these in the workplace under close supervision. Advance care planning scored the lowest, indicating performance in a simulated setting. A wide range of stakeholders validated a palliative care competency framework for undergraduate medical curricula. This framework can be used to guide teaching about palliative care.
Interprofessional education allows students to collaborate with students and professionals of multiple disciplines. An Interdisciplinary Palliative Care (IPC) Seminar, held in the Midwest, involves students from disciplines of medicine, nursing, pharmacy, social work, and chaplaincy. The curriculum of the seminar incorporates asynchronous and synchronous didactic presentations, experiential learning through group exercises and discussion, along with home visits by students in interdisciplinary dyads. The purpose of this study was to determine whether students’ participation in a 3-week IPC seminar would positively influence their socialization and value of interprofessional collaboration with the ultimate goal of developing skilled professionals who engage in interprofessional practice in hospice and palliative care settings. This descriptive study invited participants to take a pre- and postseminar online survey using the Interprofessional Socialization and Valuing Scale-21 (ISVS-21) to assess shifts in students’ perceptions of interprofessional socialization and the value of collaborative health-care practice. In their pre-and postseminar scores, 71 participants reported they more strongly agreed with all items on the ISVS-21 after completing the seminar. The results from this study suggest the IPC Seminar is an effective educational model for advancing the value of interprofessional socialization and collaborative practice in hospice and palliative health-care.
Background: The number of medical undergraduate and postgraduate students completing palliative care clinical rotations in Canadian medical schools is currently unknown. The aim of this study was to assess the proportion of Canadian medical trainees completing clinical rotations in palliative care and to determine whether changes took place between 2008 and 2018.
Methods: In this descriptive study, all Canadian medical schools (n = 17) were invited to provide data at the undergraduate and postgraduate levels (2007/08–2015/16 and 2007/08–2017/18, respectively). Information collected included the number, type and length of palliative care clinical rotations offered and the total number of medical trainees or residents enrolled at each school.
Results: All 17 Canadian medical schools responded to the request for information. At the undergraduate level, palliative care clinical rotations were not offered in 2 schools, mandatory in 2 and optional in 13. Three schools that offered optional rotations were unable to provide complete data and were therefore excluded from further analyses. In 2015/16, only 29.7% of undergraduate medical students completed palliative care clinical rotations, yet this was a significant improvement compared to 2011/12 (13.6%, p = 0.02). At the postgraduate level, on average, 57.9% of family medicine trainees completed such rotations between 2007/08 and 2016/17. During the same period, palliative care clinical rotations were completed by trainees in specialty or subspecialty programs in anesthesiology (34.2%), geriatric medicine (64.4%), internal medicine (30.9%), neurology (28.2%) and psychiatry (64.5%).
Interpretation: Between 2008 and 2018, a large proportion of Canadian medical trainees graduated without the benefit of a clinical rotation in palliative care. Without dedicated clinical exposure to palliative care, many physicians will enter practice without vital palliative care competencies.
Previous literature demonstrates that current palliative care training is in need of improvement for medical students in global, European and Canadian contexts. The training of medical undergraduates is key to ensure that the ongoing and increasing need for enhanced access to palliative care across all settings and communities is met. We describe building a comprehensive palliative and end-of-life care curriculum for medical undergraduates at our university. As with recent European and US studies, we found that the process of university curriculum renewal provided a critical opportunity to integrate palliative care content, but needed a local palliative care champion already in place as an energetic and tireless advocate. The development and integration of a substantive bilingual (English and French) palliative and end-of-life care curriculum over the 4-year medical undergraduate program at our university has occurred over the course of 14 years, and required multiple steps and initiatives. Subsequent to the development of the curriculum, there has been a 13-fold increase in students selecting our palliative care clinical rotations. Critical lessons learned speak to the importance of having a team vision, interprofessional collaboration with a focus on vision, plans and implementation, and flexibility to actively respond and further integrate new educational opportunities within the curriculum. Future directions for our palliative care curriculum include shifting to a competency-based training and evaluation paradigm. Our findings and lessons learned may help others who are working to develop a comprehensive undergraduate medical education curriculum.
BACKGROUND: Caring for patients in the end-of-life is an emotionally and physically challenging task. Therefore, undergraduate nursing students (UNS) need opportunities to learn to care for the dying patient. This study aimed to describe UNS' experiences of caring for patients at end-of-life.
METHODS: Interviews with 16 UNS in their last semester of nursing education were conducted. Data were analyzed with a phenomenological approach.
RESULTS: The UNS created a professional relationship with the dying patient. It meant that when the patient was unable to speak for themselves, the UNS could still meet his/her wishes and needs. The UNS believed they could take responsibility for the patient who was no longer able to take responsibility for themselves. Meeting with the patient's family could be experienced with anxiousness but was dependent on the personal chemistry between the patient's family and the UNS.
CONCLUSION: The UNS creates a relationship with the patient and their family. To be knowledgeable about the patient's physical and psychosocial needs means that the UNS can support the patient in the end-of-life phase. Being close to the patient and the family results in an intensity of emotions in the care situation. The UNS can receive support from their colleagues during processing their emotions and creating an experience from their encounters with patients in end-of-life care.
BACKGROUND: Providing care for dying people and the death of patients are stressing situations faced by nursing students during their clinical practice. Learning about palliative care improves the management of emotions and the ability to cope when caring for patients in end-of-life processes. However, there is little knowledge on the effect of this learning on the students' perceptions of their own death.
OBJECTIVES: To determine the effect of a palliative care course on the thoughts of nursing students about their own death.
DESIGN: A qualitative, descriptive, and comparative study was conducted based on content analysis, administering an open-ended questionnaire on dying and death at the start and end of a palliative care course.
PARTICIPANTS: The study included 85 volunteers studying Palliative Care in the second year of their Nursing Degree at the University of Granada (Spain).
RESULTS: Students described their perceptions in more detail after the course, with more numerous code citations, and their post-course responses evidenced a reduction in anxiety about their own death and an increased recognition of the need to respect the decisions of patients for a dignified death.
CONCLUSIONS: Palliative care learning modifies the perception by nursing students of their own death and their understanding of a dignified death, which may enhance the care they deliver to patients at the end of life.
BACKGROUND: Despite advances in medical care, pediatric deaths are still an unfortunate reality. Most of these deaths occur within a hospital setting. End-of-life care is an important part of medical care for children with serious illnesses. Despite the importance, pediatric providers report a lack of comfort surrounding end-of-life care.
OBJECTIVE: To assess categorical pediatric residents' perceptions and participation in providing end-of-life care to dying children and their families.
STUDY DESIGN: This is a survey-based, descriptive, mixed-methods study. Survey was sent to categorical pediatric residents at Indiana University School of Medicine in June 2018 to obtain both quantitative and qualitative information on resident perception and participation in end-of-life care. Surveys were sent to 100 residents with a response rate of 68%.
SETTING/PARTICIPANTS: Pediatric residents at Indiana University School of Medicine.
RESULTS: The comfort and participation in end-of-life care are limited in all levels of pediatric training. Residents do not feel comfortable with 19 of 22 questions related to end-of-life care. Only 32% of residents felt their education prepared them to participate in end-of-life care. Almost one-fifth (19.5%) of residents report participating in zero aspect of end-of-life care. Themes discussed by residents include education, experience, communication, social norms, emotions, self-care, comfort, and family.
CONCLUSION: More formalized education and training is needed to increase resident comfort with and participation in end-of-life care. Such future interventions should focus on communication surrounding difficult conversations and providing guidance for families.
Identifying the degree of attitudes has a critical effect on the application of hospice and palliative care. However, studies on hospice and palliative care attitudes highlight only statistically significant outcomes and do not propose comprehensive conclusions or generalizations about attitudes. Therefore, we conducted a systematic review to synthesize and appraise articles that analyzed nurses' attitudes regarding palliative care services. After compiling, the finally selected 13 articles indicated that influencing factors on nurses' attitudes were experience in caring for the dying, career or education level, knowledge and education toward hospice and palliative care, religious belief, death (education and anxiety), and age. Most nurses and nursing students displayed positive cognition and attitudes, yet a low level of knowledge. These results show that an introduction of hospice and palliative care education and practical training in nursing curricula is necessary. And such implementation should take place within sanatoriums as well, where attending the terminally ill takes place at all times. Because hospice and palliative care is usually provided by a multidisciplinary team, it is necessary to identify which factors influence each member of the team likewise. It is anticipated this study will become a preliminary basis for such research.
BACKGROUND: The U.S. health care system is poorly designed to meet the needs of patients at the end of life (EOL) and their families. Nursing students often have reported feeling inadequate to provide EOL care.
METHOD: Following an EOL simulation, reflective journals were collected from junior and senior nursing students and analyzed for themes using qualitative content analysis. The condensed meaning units were abstracted into codes based on Carper's fundamental patterns of knowing.
RESULTS: Thirty-one junior and senior nursing students (mean age, 21.04 ± 0.52 years, 96.2% female) in a baccalaureate program participated in the study. The broad themes of student reflections included empirics (theoretical or natural historical) aesthetics (transformative nursing action), personal (interpersonal process of nurse-patient interaction), and ethics (emotion influences actions).
CONCLUSION: Student perception and participation in all roles contributes to the gestalt of the experience of a highly emotional EOL simulation for both students and faculty.
Caring for the dying patient can be stressful for nursing students. The purpose of this study was to describe a multimodal educational intervention designed to improve nursing students' attitude toward care of the dying patient and the family. Sophomore nursing students participated in an interactive end-of-life (EOL) lecture and simulation. A quasi-experimental, pretest/posttest design with a convenience sample was used for this study. Frommelt Attitudes Toward Care of the Dying version A was used to measure attitudes toward care of the dying patient before and after educational intervention. In addition, students were given an open-ended questionnaire to reflect on their perceptions of the EOL experience and a demographic questionnaire. A paired t test revealed a statistically significant difference between the pretest and posttest (t50 = 3.1, P = .003) on the Frommelt Attitudes Toward Care of the Dying, suggesting that students gained a more positive attitude toward caring for the dying patient. Three themes emerged from the content analysis and included knowing what to say and how to offer presence, becoming emotionally prepared, and learning skills to comfort. The use of lecture and simulation allowed students to assimilate the knowledge and affective skills needed to provide quality EOL care.
PURPOSE: International health electives (IHEs) provide numerous educational benefits; potential harms are less well understood. One potential harm is trainee distress associated with increased patient death during IHEs. The purpose of this study was to explore residents' and fellows' IHE experiences with patient death.
METHOD: The authors used applied thematic analysis to explore residents' and fellows' IHE experiences with patient death. The Mayo International Health Program supports IHEs from all specialties across three Mayo Clinic sites. Data were collected and analyzed in two steps. First the authors collected, coded, and analyzed narrative reflections from 43 postrotation reports gathered in 2001-2017 and identified themes relating to experiences with patient death. Second, in 2016-2017 the authors conducted semistructured interviews with six previous participants to refine thematic analysis.
RESULTS: Participants described impacts of experiencing increased patient death and identified themes in two domains: difficult experiences with patient death and potential interventions to help residents process their experiences. They identified four themes illustrating why these experiences were difficult: lack of preparation for increased exposure to death, lack of closure, consequences of limited resources, and differences in cultural beliefs regarding death. While pretrip preparation for dealing with death was viewed as important, trainees identified support during and debriefing after IHEs as additional important interventions.
CONCLUSIONS: Given the popularity of IHEs, residency programs should consider the effect on trainees of increased exposure to patient death. Study findings can inform IHE preparation, support, and debriefing to minimize distress associated with witnessing patient deaths on IHEs.
Effective team communication is necessary for the provision of high-quality health care. Yet, recent graduates from diverse health-care disciplines report inadequate training in communication skills and end-of-life care. This study explored the impact of a withdrawal of life-sustaining measures interprofessional simulation on team communication skills of students representing medicine, nursing, and social work. The 3-phase simulation required teams to communicate with the patient, family, and one another in the care of a seriously ill patient at the end of life. Team communication in the filmed simulations was analyzed via the Gap-Kalamazoo Communication Checklist. Results revealed fair to good communication across the 9 communication domains. Overall team communication was strongest in “shares information” and lowest in “understands the patient’s and family’s perspective” domains. Field notes revealed 5 primary themes—Team Dynamics, Awkwardness, Empathy is Everything, Build a Relationship, and Communicating Knowledge When You Have It—in the course of the data analysis. Logistical challenges encountered in simulation development and implementation are presented, along with proposed solutions that were effective for this study. This simulation provided an opportunity for interprofessional health-care provider students to learn team communication skills within an end-of-life care context.
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.
This study explores how medical students feel about caring for terminally ill patients as well as how their medical courses prepare them for addressing end-of-life (EOL) issues with patients. Four hundred and five Mexican medical students were surveyed through the Student Views on Death questionnaire. The vast majority of students (94%) felt that physicians should inform patients of their impending death. Most students said they felt comfortable talking with (61%) or examining (76%) terminally ill patients. However, only half the students actually talked with patients about death. Participants in our study were interested in learning about EOL medical attention, yet most considered themselves poorly prepared to offer this type of care to terminally ill patients. The study provides objective data on a topic that has scarcely been explored in Mexico, data that will be useful in designing educational activities to improve EOL medical training.
Palliative care (PC) is an essential part of the healthcare system, aiming to improve the quality of life of terminally ill patients and their families through prevention, relief of suffering, and providing psychosocial and spiritual support. To achieve high-quality PC, medical education should encompass PC training, including knowledge of PC, and skills and attitudes towards PC, at the undergraduate level. The aim of this study is to identify PC knowledge and experience among undergraduate medical and nursing students at Sultan Qaboos University (SQU), a government university in Oman. A validated questionnaire that measures knowledge and experiences of PC was administered to all final year medical and nursing students (N = 196) at SQU. The majority of the students (93.4%) were aware of the term PC, but most of them (68.9%) did not have any experience of PC. Around half of the students (54.9%) had a vague notion of how to implement PC, and only 41.3% felt confident in providing PC for terminally ill patients. Less than half of the students (44.8%) were aware that the patient’s family should be included in PC, as well as the patient. The majority of students (71.3%) thought that PC should be included in the undergraduate teaching curriculum, though few students (17.9%) knew that PC is currently a specialized medical unit (sub-department) in Oman. Most of the students (73.0%) thought that terminally ill patients have the right to choose “do not resuscitate,” but few students agreed that patients should be able to request a lethal dose (24.0%) or consent to a physician-assisted suicide (35.7%). Most of the students (84.7%) believed that special psychological support should be provided for doctors and nurses working in PC. Bivariate analysis showed no significance in the knowledge of applied PC in relation to which of the colleges the students were from (p = 0.283) or gender of the students (p = 0.068). Despite the fact that SQU students had favorable attitudes towards PC, they have insufficient knowledge and lack of experience. As the number of geriatric and terminal cancer patients increases across Oman, there is a need for the healthcare system to provide high-quality and effective PC services. Thus, there is an urgent need to integrate PC teaching courses as part of the undergraduate medical education for medical and nursing students.
The descriptive study was conducted to investigate the knowledge, opinions, behaviors of senior nursing students regarding euthanasia and factors in Islam influencing these. Almost all students (97.7%) knew about euthanasia. Their knowledge, opinions and behaviors were affected by their beliefs about death, religious beliefs and the idea of being subject to euthanasia themselves. Religion influenced whether they wanted euthanasia to be legalized or would carry it out secretly. Students who would be willing for their relatives to undergo euthanasia would not want to participate in this. Knowledge about the concept of euthanasia should be increased and the subject further investigated in many dimensions.
OBJECTIVE: The purpose of this study is to understand the attitude of undergraduate nursing students toward advanced care planning (ACP) and their willingness to implement ACP and to analyze its influencing factors, so as to provide evidence-based basis for life and death education and ACP-related training in colleges and universities.
METHODS: A total of 312 nursing undergraduates from a university in Chengdu (China) were surveyed by using general information questionnaire, attitude scale of ACP, and willingness questionnaire to implement ACP.
RESULTS: The scores of undergraduate nursing students' attitude toward ACP were 24.97 ± 2.75, and the scores of total willingness to ACP were 79.26 ± 9.70. Univariate analysis and multivariate linear regression analysis showed that religious belief, grade, family relationship, and family discussion of death were the factors influencing the willingness of nursing students to carry out ACP.
CONCLUSIONS: The attitude of undergraduate nursing students toward ACP tended to be positive, but their cognition of ACP was misunderstood, and their willingness to implement ACP needed to be improved. To improve the awareness and implementating willingness of undergraduate nursing students to ACP, it was recommended that colleges and universities carried out systematic standardized life and death education courses and ACP-related training.