Background: Recognising dying is a key clinical skill for doctors, yet there is little training.
Aim: To assess the effectiveness of an online training resource designed to enhance medical students’ ability to recognise dying.
Design: online multicentre double-blind randomised controlled trial (NCT03360812). The training resource for the intervention group was developed from a group of expert palliative care doctors’ weightings of various signs/symptoms to recognise dying. The control group received no training.
Setting/participants: Participants were senior UK medical students. They reviewed 92 patient summaries and provided a probability of death within 72 hours (0% certain survival – 100% certain death) pre, post, and 2 weeks after the training. Primary outcome: (1) Mean Absolute Difference (MAD) score between participants’ and the experts’ scores, immediately post intervention. Secondary outcomes: (2) weight attributed to each factor, (3) learning effect and (4) level of expertise (Cochran–Weiss–Shanteau (CWS)).
Results: Out of 168 participants, 135 completed the trial (80%); 66 received the intervention (49%). After using the training resource, the intervention group had better agreement with the experts in their survival estimates (dMAD = -3.43, 95% CI -0.11 to -0.34, p = <0.001) and weighting of clinical factors. There was no learning effect of the MAD scores at the 2-week time point (dMAD = 1.50, 95% CI -0.87 to 3.86, p = 0.21). At the 2-week time point, the intervention group was statistically more expert in their decision-making versus controls (intervention CWS = 146.04 (SD 140.21), control CWS = 110.75 (SD 104.05); p = 0.01).
Conclusion: The online training resource proved effective in altering the decision-making of medical students to agree more with expert decision-making.
Background: Advance directives have been established as a legal document that ensures patients' wishes are followed if/when they cannot make medical decisions for themselves. The concept, advance directive, is rooted in the ethical principle of patient's autonomy. New York State recognizes three types of advance directives: New York State Health Care Proxy, Living Wills, and Do Not Resuscitate (DNR) order. A common misnomer in healthcare is the idea that advance directives are for the elderly or patients with terminal illness. As per New York State statutes, everyone older than 18-years-old should have an advance directive to avoid conflicts in times of crisis. It has been shown that most patients believe it is their physician's responsibility to initiate an advance directive discussion and residents are at the forefront of most health facilities.
Objective: To assess the knowledge and attitude of internal medicine residents towards advance directive and to improve residents' skills and confidence on advance directive discussion.
Design: We carried out a prospective study to assess the knowledge and attitude of the internal medicine residents towards advance directive to validate the need to implement didactic sessions and simulations. Results: Fifty out of the 75 internal medicine residents of Harlem Hospital Center participated in the study. Most of the responders indicated that they lacked sufficient knowledge in advance directive discussion and indicated that they were interested in didactic sessions and simulations related to how to help patients with advance directives.
Conclusion: Our study showed that most of the residents lacked sufficient knowledge in advance directives discussions and the importance of its incorporation into residency training education.
Introduction: Do not resuscitate (DNR) is a medical procedure for patients who are suffering from critical, untreatable, and irreversible disease where the patient's life is predicted to end. DNR is considered a sensitive decision for patients and their relatives, as well as physicians.
Aim: This study is aimed to assess the knowledge and attitude of medical students and interns toward the DNR order and the factors affecting their attitude at the King Abdulaziz University Hospital (KAUH) in Jeddah.
Methods: Nonintervention cross-sectional study was conducted among 429 medical students (preclinical and clinical years) and interns who were given an online questionnaire between May and June in 2016 at KAUH in 18 Kingdom of Saudi Arabia.
Results: Our study indicates that most of the participants (73.2%) were familiar with DNR order; however, more than half of them (58.3%) did not take any lecture or session on DNR. Large proportion of medical students had the opinion that attending a lecture or session on DNR would help them discuss it more skillfully with the patients and their relatives. More than half of the participants (55%) believed that there is a Fatwa that regulates DNR on the Islamic level.
Conclusion: Participants, who were interns, were more familiar with the term DNR, whereas the 2nd-year medical students were less familiar with DNR. Considering the variation in the knowledge of participants about DNR, we conclude that additional lectures and sessions about DNR should be added to the medical school curriculum to make the students more confident and able in handling the DNR discussions.
Les soins palliatifs sont-ils envisageables en médecine chronique ? Quels rôles les infirmiers peuvent avoir dans cette perspective ? Que peuvent-ils apporter ?
Voici les premières questions sur lesquelles je me penche dans ce mémoire réflexif. De nombreux auteurs et même la Haute Autorité de Santé s'accordent sur un développement d'une prise en soin holistique et personnalisée pour les patients atteints de pathologies chroniques, même si le mot palliatif ne fait pas l'unanimité. La deuxième interrogation sur le rôle infirmier est plus complexe à aborder de part la diversité d'exercice mais aussi l'histoire de cette profession. Les éléments de réponse tendent à démontrer des liens unissant soins palliatifs et soins infirmiers, dans une vision holistique des patients, un respect, une remise en question du projet de soin et une place particulière dans la coordination des soins.
Ses éléments de réponse m'amènent à une dernière et indispensable interrogation : comment cela est-il réalisable ? Comment les infirmiers pourraient faciliter la mise en place des soins palliatifs ? La réponse semble simple : l'interdisciplinarité, mais elle présente des conditions à respecter.
Les articles de ce volume cherchent à comprendre la souffrance à partir de ses propres représentations et soulignent la nécessaire articulation des discours littéraires, philosophiques, psychanalytiques et médicaux pour cerner ce fait social et moral total qu'est l'expérience, vécue et vivante, de la souffrance.
All family practice residents need to know the basics about discussing end-of-life care with patients, their caregivers, and loved ones. This might entail imparting knowledge, skills, and attitudes with respect to medical assistance in dying (MAID). Medical assistance in dying became legal in 2016 (2015 in Quebec), and in the past year, about 1% of all deaths in Canada were assisted by clinicians. Different health authorities reported MAID rates of between 5% and 0.5%. As our laws and societies are similar to those of the Netherlands and Belgium, we can expect that within a few years, the rates of MAID across Canada will be 4% to 5%. This translates to 13 000 deaths annually. All family doctors must be prepared to answer questions from patients about MAID and give accurate information regardless of their personal feelings and values. Some will want to do assessments and some will also want to provide MAID for their patients. Most health authorities will have a program in place to mentor those practitioners who wish to provide MAID.
BACKGROUND: The need to provide care for the dying patient and his/her family may occur in every medical setting. Newly graduated nurses and physicians should therefore be prepared to deliver it at a high-quality level.
OBJECTIVES: To explore (a) the primary difficulties participants anticipate they will encounter whilst working with dying patients, (b) their interest in developing competencies in caring for dying patients, and (c) their interest in working in palliative/hospice settings or with dying patients in the future.
DESIGN: A cross-sectional study.
SETTINGS: A medical university in Poland.
PARTICIPANTS: Convenience sample of nursing (=112) and medical students (=101) at the end of their undergraduate education.
METHODS: Questionnaire distributed online and in hard-copy format.
RESULTS: Half of the participants anticipated experiencing various emotional and professional difficulties in caring for dying individuals, especially medical students. These difficulties pertained mostly the reaction of family members to the patient's death, addressing the psychological needs of the dying person, and coping with his/her own emotions when dealing with the patient's death. Students reported that working with dying patients could cause occupational stress - more so among medical students. The majority of them showed an interest in improving knowledge regarding palliative care and also in this case this was mostly true of medical rather than nursing students. However, more than half of the participants preferred avoiding work in palliative/hospice settings, with no differences between the two groups. Participants attributed this attitude to two factors: (a) the desire to avoid negative emotions and stress that could be triggered by dealing with death and dying; and (b) because they felt they lacked the required skills and personal abilities to handle such situations.
CONCLUSIONS: Undergraduate curricula that include strategies for coping with negative emotions associated with facing the process of death and dying should be developed. Interprofessional education should be encouraged, especially regarding the psychosocial aspects of end-of-life care.
In 2008, a Canadian strategy called the "Educating Future Physicians in Palliative and End-of-Life Care" (EFPPEC) project published national medical undergraduate competencies for palliative and end-of-life care. Since that time, there have been several changes in the practice environment. To formally incorporate these changes and also update the competencies for EFPPEC, an EFPPEC update project team was established in 2017. The EFPPEC update document in English was finalized in June 2018, and subsequent minor amendments to the French version were completed in January 2019. This report describes the process and also shares the new updated EFPPEC competencies with the wider palliative care community.
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.
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.
As interns, new doctors care for the dying or others who have palliative care (PC) needs. Undergraduate medical students need to learn about PC Up to half of newly qualified doctors are underprepared for end of life issues and many feel it is a source of distress. Medical students value palliative education but many feel training is deficient.
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BACKGROUND: Undergraduate teaching currently fails to adequately prepare doctors to deliver 'end-of-life' care. Despite much evidence supporting simulation-based teaching, its use in medical undergraduate palliative and 'end-of-life' care curricula remain low.
AIM: This study assesses whether simulation can improve the confidence and preparedness of medical students to provide holistic care to dying patients and their families, from clinical assessment to symptom management, communication and care after death.
METHODS: Six fourth-year medical students undertook individual simulations involving a dying patient (high-fidelity simulator) and family member (actor). Intentional patient death occurred in four of the six scenarios (although unexpected by students). Pre-simulation/post-simulation thanatophobia questionnaires measured student attitudes towards providing care to dying patients. Thematic analysis of post-simulation focus group transcripts generated qualitative data regarding student preparedness, confidence and value of the simulations.
RESULTS: Thematic analysis revealed that students felt the simulations were realistic, and left them better prepared to care for dying patients. Students coveted the 'safe' exposure to dying patient scenarios afforded by the simulations. Observed post-simulation reduction in mean thanatophobia scores was not found to be statistically significant (p=0.07).
CONCLUSIONS: Results suggest a feasible potential for simulations to influence undergraduate medical student teaching on the care of a dying patient and their family. We believe that this study adds to the limited body of literature exploring the value of simulation in improving the confidence and preparedness of medical students to provide 'end-of-life' care. Further research into the cost-effectiveness of simulation is required to further support its application in this setting.
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.
Introduction: Sick persons need doctors who understand their pathology, know how to treat their problem, and accompany them through their illness. This study aimed to synthesize the state of knowledge regarding the concept of value-based medicine (VBM) through an integrative literature review, and establish how VBM can be applied in palliative care. Areas covered: An integrative review was conducted with the keywords 'value-based medicine,' 'patient-centered care,' and 'medicina baseada em valor' (Portuguese for VBM) in PubMed and Virtual Health Library, identifying 17,189 articles in total. Of these, 10 articles met the eligibility criteria. VBM combines the highest level of technical-scientific data with patients' values. It is defined as the combination of evidence-based medicine, patient-centered care, and cost-effectiveness. Patients' values are a set of preferences, concerns, and expectations that contribute toward accommodating their needs in the treatment clinic. Expert opinion: Like VBM, palliative care focuses on patients' values and quality of life, respecting natural limits. The early development of a care plan with active participation of the patient in the face of life-threatening diseases should be encouraged and can bring peace and comfort in a person's final moments.
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.
Background: Advance care planning (ACP) is a critical component of end-of-life (EoL) care, yet infrequently taught in medical training.
Objective: We designed a novel curriculum that affords third-year medical students (MS3s) the opportunity to practice EoL care discussions with a trained older adult in the patient's home.
Design: Volunteers were instructed as trained patients (TPs) to evaluate MS3s interviewing and communication skills. The MS3s received a didactic lecture and supplemental material about ACP. Pairs of MS3s conducted ACP interviews with TPs who gave verbal and written feedback to students. Student evaluations included reflective essays and pre/postsurveys in ACP skills.
Settings and Participants: A total of 223 US MS3s participated in the curriculum.
Results: Qualitative analysis of reflective essays revealed 4 themes: (1) students' personal feelings, attitudes, and observations about conducting ACP interviews; (2) observations about the process of relationship building; (3) learning about and respecting patients' values and choices; and (4) the importance of practicing the ACP skills in medical school. Students' confidence in skills significantly improved in all 7 domains (P < .001): (1) introduce subject of EoL; (2) define advance directives; (3) assess values, goals, and priorities; (4) discuss prior experience with death; (5) assess expectations about treatment and hospitalization; (6) explain cardiopulmonary resuscitation and outcomes; and (7) deal with own feelings about EoL and providers' limitations.
Conclusions: The use of older adults as TPs in an ACP curriculum provides students an opportunity to practice skills and receive feedback in the nonmedical setting, thereby improving comfort and confidence in approaching these conversations for future patients.
OBJECTIVES: Having early discussions with seriously ill patients about their priorities and values can improve their peace of mind and family outcomes during bereavement; however, physicians and medical students report feeling underprepared to hold serious illness conversations. We evaluated the impact of the Serious Illness Care Program clinician training workshop on medical learners' knowledge of comfort and confidence in holding such conversations.
METHODS: Eligible learners were penultimate- or final-year medical students or first-year residents of generalist programs (Family Medicine, Internal Medicine). Learners participated in a 2.5-hour workshop involving reflection on serious illness discussions, didactic teaching and demonstration of the Serious Illness Conversation Guide (SICG), role play with standardized patients, direct observation, and feedback from experts. Participants completed pre- and post-intervention questionnaires with Likert-type scale and open-ended questions, which were analyzed using paired t tests and qualitative content analysis, respectively.
RESULTS: We enrolled 25 learners. The intervention was associated with an increase in knowledge (P < .001) and self-efficacy (P < .001). All learners reported gaining new skills, with a majority specifically identifying a framework for structuring serious illness conversations in the qualitative analysis (n = 14, 56%). Participants stated the workshops would improve their comfort in holding serious illness conversations (n = 24, 96%), and that it would be valuable to integrate the workshops into their formal curricula (n = 23, 92%).
CONCLUSIONS: Training on the use of the SICG is novel for medical students and first-year residents and associated with the improvement in their knowledge of and perceived capacity to hold serious illness conversations. This study suggests that the integration of SICG training into medical curricula may have educational value.
Cet ouvrage réunit l'intégrallité du programme, les recommandations et les cours officiels, des données de la banque nationle d'entraînement Sides ainsi que les informations indispensables à connaître pour se préparer aux ECNi (Epreuves Classantes Nationales informatisées).
Objective: Neurosurgeons care for critically ill patients near the end of life, yet little is known about how well their training prepares them for this role. We surveyed a random sample of neurosurgery residents to describe the quantity and quality of teaching activities related to serious illness communication and palliative care, and resident attitudes and perceived preparedness to care for seriously ill patients.
Methods: A previously validated survey instrument was adapted to reflect required communication and palliative care competencies in the 2015 the Accreditation Council for Graduate Medical Education (ACGME) Milestones for Neurological Surgery. The survey was reviewed for content validity by independent faculty neurosurgeons, piloted with graduating neurosurgical residents, and distributed online in August 2016 to neurosurgery residents in the United States using the American Association of Neurological Surgeons (AANS)/Congress of Neurological Surgeons (CNS) Joint Section on Neurotrauma and Critical Care email listserv. Multiple choice and Likert scale responses were analyzed using descriptive statistics.
Results: Sixty-two responses were recorded between August 2016 and October 2016. Most respondents reported no explicit teaching on: explaining risks and benefits of intubation and ventilation (69%), formulating prognoses in neurocritical care (60%), or leading family meetings (69%). Compared to performing craniotomies, respondents had less frequent practice leading discussions about withdrawing life-sustaining treatment (61% vs. 90%, p < 0.01, "weekly or more frequently"), and were less often observed (18% vs. 87%, p < 0.01) and given feedback on their performance (11% vs. 58%, p < 0.01). Nearly all respondents (95%) felt "prepared to discuss withdrawing life-sustaining treatments," however half (48%) reported they "would benefit from more communication training during residency." Most (87%) reported moral distress, agreeing that they "participated in operations and worried whether surgery aligned with patient goals."
Conclusions: Residents in our sample reported limited formal training, and relatively less observation and feedback, on required ACGME competencies in palliative care and communication. Most reported preparedness in this domain, but many were receptive to more training. Better quality and more consistent palliative care education in neurosurgery residency could improve competency and help ensure that neurosurgical care aligns with patient goals.