Educating psychiatry residents about death and dying. A national survey

Few U.S. public health schools offer courses on palliative and end-of-life care policy

BACKGROUND

Palliative care has been identified by the World Health Organization (WHO) as a critical policy element for the relief of suffering, yet palliative care policy receives minimal attention in mainstream U.S. public health journals, conferences, or textbooks. In the '90s, documentation of the lack of attention to end-of-life and palliative care in medical and nursing curricula led to concerted efforts to improve medical and nursing education in palliative care. No such educational effort has yet been directed toward public health professionals.

OBJECTIVE

This study's objective was to quantify current course offerings covering palliative and end-of-life care from a public health and health policy perspective at accredited schools of public health.

DESIGN

Using a list of keywords about palliative and end-of-life care, the research team searched publicly accessible websites of all CEPH accredited and affiliated U.S. schools of public health to identify courses that included relevant content about palliative care.

RESULTS

For academic years 2011/12 and 2012/13, 3 (6%) of the 49 accredited U.S. schools of public health offered a full course covering public health issues in palliative care. Six schools (12%) included some palliative care content in related courses such as gerontology policy.

CONCLUSIONS

Schools of public health are not preparing future policy experts with a basic knowledge of the components and systems of palliative care and hospice. Development and dissemination of appropriate curricular material to address the public health and policy aspects of palliative care is needed to address this gap.

A medical resident inpatient hospice rotation: experiences with dying and subsequent changes in attitudes and knowledge

PURPOSE

To evaluate intern experience in end-of-life care and self-assessed changes in attitude and knowledge, following a mandatory rotation on an inpatient hospice and in a nursing home.

SUBJECTS AND METHODS

Twenty-seven interns enrolled in an internal medicine residency program completed a questionnaire examining experiences with dying patients, prior training in end-of-life care, and self-ratings of pertinent attitudes and knowledge. The questionnaire used a retrospective before and after design. Comparisons were evaluated using dependent two-tailed r-tests.

RESULTS

Prior training was largely limited to undergraduate didactic courses. Few interns had received formal training in symptom management. Most felt poorly prepared to care for terminally ill patients. Eighty-two percent of interns had previously cared for a dying patient only in acute care. Fifty-nine percent had never cared for a dying patient without intravenous fluids. Prior modeling of end-of-life care communication by attending physicians was uncommon. On a 5-point scale (strongly disagree-strongly agree) mean responses increased from 2.1 before-rotation to 3.0 after-rotation (p < 0.001) for the statement, "I feel as comfortable with a dying patient as I do with any other patient." Pain management knowledge increased from 2.0 before-rotation to 3.8 after-rotation (p < 0.001). Seventy-seven percent strongly agreed with the statement, "some training in care of terminally ill patients should be mandatory for all internists."

CONCLUSIONS

Prior experiences did not adequately prepare interns to deliver competent care. Significant improvements in attitude and knowledge were noted following the intervention. More hands-on clinical experiences in end-of-life care for residents are needed. Occasional didactic sessions will be inadequate.

Palliative Care Education: An Intervention to Improve Medical Residents' Knowledge and Attitudes

BACKGROUND

Medical care at the end of life remains poor. One approach to improving end-of-life care is through education of medical trainees. However, evidence regarding the structure of an ideal educational intervention is sparse.

OBJECTIVE

To test an innovative curriculum designed to improve medical resident knowledge and decrease anxiety surrounding end-of-life care.

METHODS

Quasiexperimental study of medical trainees in a large academic internal medicine residency. Attitudes and knowledge were measured at baseline and at completion of a 1-month clinical ward rotation for both control (n = 40) and intervention groups (n = 30) using the Collett-Lester Death Anxiety Scale (C-LDAS), the Semantic Differential Scale (SDS), and a 16-question knowledge-based test. Residents in the intervention group completed four 1-hour sessions focused on end-of-life issues.

RESULTS

Baseline anxiety levels were high while knowledge scores were poor. Linear regression modeling demonstrated that pretest scores were the strongest predictor of post-test scores for all three measures. Additional significant predictors for the knowledge test were prior palliative care experience and year of training (p = 0.02), while prior palliative care experience alone contributed to the SDS model (p = 0.06). No significant improvements on the SDS, C-LDAS, or knowledge test occurred after the curriculum intervention.

CONCLUSIONS

Our classroom intervention had no significant effect on residents' attitudes towards or knowledge of end-of-life care. The fact that prior palliative care experience affects baseline scores provides a strong argument for continued research for an effective curriculum for end-of-life education, perhaps focusing on clinical rather than didactic experiences in palliative care.

C.A.R.E.: an approach for teaching ethics in medicine

Various societal factors have contributed to an increase in the ethical dilemmas faced by physicians, yet limited formal training in ethical decision-making is provided for those practitioners during their medical education. The pluralistic nature of contemporary medicine seems amenable to the development of common clinical and educational approaches to ethical dilemmas. The authors propose one such framework--a four question approach called C.A.R.E.--that encourages physicians at all levels of training to acknowledge individual and collective factors that enter into ethical decision-making. These questions are clearly described, and examples for use of the model in teaching settings are also provided. The authors believe that this approach can have significant utility in medical education and clinical settings, and advocate for its use and evaluation.

Communication skills and psychological training in oncology

Preserving the best possible quality of life for cancer patients and their families has become a major goal in cancer care. However, the cumulative effect of stressors related to cancer care, many of which involve communicating with patients and relatives, may lead to the development of burnout in staff. Many health care professionals lack the psychosocial knowledge and communications skills needed to identify patients' problems because general professional training focuses on technical care. Teaching strategies known as psychological training programs (PTP) are therefore being developed to help improve health care professionals' sensitivity to communication problems with patients and relatives. Cognitive (e.g. theoretical information), experiential (e.g. case-history discussions), behavioural (e.g. role-playing exercise) and supportive (e.g. stressor identification) training techniques are used to teach the essential skills of good communication, i.e. listening, empathy, response to cues and appropriate use of reassurance. PTP range from one-day courses and residential workshops to full-time 1- or 2-year curricula. However, one of the main obstacles to implementing PTP is scepticism among health care professionals about its usefulness. Research on training effectiveness should therefore be developed to assess the impact of communication skills on quality of care and patients' quality of life.

Is experience a good teacher? How interns and attending physicians understand patients' choices for end-of-life care. SUPPORT Investigators. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments

BACKGROUND

Recent studies have shown that physicians do not accurately assess patients' health status or treatment preferences. Little is known, however, about how physicians' levels of training or experience relate to their abilities to assess these preferences. To better understand this phenomenon, the authors compared the abilities of medical interns and attending physicians to predict the choices of their adult patients for end-of-life care.

METHODS

230 seriously-ill adult inpatients were surveyed about their desires for cardiopulmonary resuscitation, their current quality of life, and their attitudes toward six other common adverse outcomes. The medical intern and attending physician who cared for these patients were asked to estimate the patient's responses for all of the same items. Agreement was assessed using the kappa statistic.

RESULTS

Compared with interns, attending physicians had known patients longer, had talked with patients more frequently about prognosis, and felt they knew more about their patients' preferences (all p < .0001). Despite this, the attending physicians were no more accurate than the interns in assessing patients' preferences. Both interns and attending physicians had only a fair understanding of patients' preferences for cardiopulmonary resuscitation or their quality of life (kappa statistics 0.32 to 0.47), and even less understanding of their willingness to tolerate adverse outcomes (kappa statistics -0.03 to 0.37).

CONCLUSIONS

For this cohort of seriously ill patients, neither medical interns nor their attending physicians were consistently accurate in assessing patients' preferences, and attending physicians were not more accurate than medical interns. Attending physicians should not assume that they can infer patients' preferences any better than the interns caring for these hospitalized patients.

Psychiatry and physician-assisted suicide

The psychiatric literature on physician-assisted suicide is scant and almost universally opposed to legalization. This opposition stems from the traditional perspective of suicide as a symptom of mental illness and the tendency of psychiatrists to extend their view of suicide in the medically well to the terminally ill. This article examines the basis for and validity of this opposition and makes recommendations about the role of the psychiatrist in physician-assisted suicide.

Programa educativo sobre muerte y cuidados paliativos en los profesionales de la salud

Introducción: La relación existente entre el personal de salud y la muerte, tienen una inevitable implicación emocional, ya que se vive y convive cotidianamente con la muerte. Objetivo: Conocer el efecto de un Programa Educativo sobre Muerte y Cuidados Paliativos (PEMyCP), fundamentado a partir de la noción de enfermedad y muerte en México. Método: Estudio cuasiexperimental comparativo, muestreo no probabilístico por conveniencia, diseño pretest-postest de un solo grupo, con profesionales de la salud en México. Los instrumentos utilizados fueron: Escala de actitudes ante los cuidados paliativos, Cuestionario de competencias profesionales y Escala de ansiedad ante la muerte de Templer. A través de análisis de frecuencias, pruebas t para muestras relacionadas y análisis de varianza ANOVA. Resultados: El PEMyCP tuvo un impacto positivo en las actitudes ante los cuidados paliativos (t=-2,0050, p=0,44), en las capacidades profesionales (t=6.969, p<0.0001), y ansiedad ante la muerte (t=2,991, p=0,15). Se realizó un ANOVA, encontraron cambios significativos en conocimientos (F=8,5988, p <0,0001) y habilidades (F=6,1197, p<0,0001); sin embargo, no se identificaron cambios en actitudes (F=0,76131, p=0,63738). En la ansiedad ante la muerte, se aprecian diferencias estadísticamente significativas (F=4,0048, p=0,00919). Conclusiones: El PEMyCP tuvo un impacto favorable en conocimientos, habilidades y ansiedad ante la muerte, no siendo así en las actitudes ante la muerte y los cuidados paliativos, ya que se requiere de mayor tiempo para lograr modificarlas debido a que se adquieren no solo aspectos cognitivos, sino también afectivos y conductuales a través de la propia experiencia.