Fifth-Year Medical Students' Knowledge of Palliative Care and Their Views on the Subject

Palliative Care in Turkey: Insights from experts through key informant interviews

BACKGROUND

The rising demand for palliative-care (PC) in Turkey, driven by cancer, has prompted increased attention since the national PC policy in 2010. Despite this, the healthcare system predominantly focuses on curative care, lacking PC integration. This is due to combination of administrative obstacles, fragmented coordination, education and training scarcity. Thus urgent strategies are required to address the growing PC gap. This qualitative study explores the perspectives of PC professionals and policymakers, providing valuable insights for national policy and program development.

MATERIAL AND METHOD

This study employed an exploratory approach using key informant interviews. Interviews were conducted using semi-structured questionnaire. It sought to collect relevant contextual information in order to achieve its aim. Thematic content analysis was employed to examine and interpret the data.

RESULT

Twenty-one participants, comprising nurses, specialists, and oncologists, were interviewed. The findings are encompassed by eight themes. 1) Integrated Care, highlights the importance of cohesive collaboration among diverse healthcare providers, social care services, and primary care systems to ensure comprehensive and effective care. 2) Meeting social care needs underscores significance of addressing a wide spectrum of patient requirements, including psychosocial support. 3) PC education emphasizes necessity of equipping healthcare professionals with the requisite skills and knowledge through comprehensive training. 4) Legalizing do-notresuscitate orders draws attention to the critical discussion surrounding end-of-life decisions. 5) Empowering communities recognizes bridging knowledge gaps among patients and caregivers. 6) Decision-Making underscores the importance of informed and collaborative decision-making processes. 7) Cultural considerations urge the adoption of culturally sensitive approaches. 8) Ongoing challenges shed light on persistent issues such as provider attitudes, and administrative hurdles.

CONCLUSION

This study highlights essential factors for establishing an integrated PC program for cancer patients in Turkey. The existing healthcare system in Turkey offers opportunities for advanced PC. Successful implementation demands strategic actions to facilitate meaningful transformation.

"Give My Daughter the Shot!": A Content Analysis of the Depiction of Patients with Cancer Pain and Their Management in Hollywood Films

INTRODUCTION

Cinemeducation, the pedagogical use of films, has been used in a variety of clinical disciplines. To date, no studies have looked at the use of film depictions of cancer pain and its management in clinical education. We investigated how patients with cancer pain and their management are depicted in Hollywood films to determine whether there is content that would be amenable to use for cancer pain assessment and management education.

METHODS

A qualitative content analysis was performed. Films that contained characters with or references to cancer pain were searched for using the International Movie Database, the Literature Arts Medicine Database, the History of Medicine and Medical Humanities Database, and Medicine on Screen. After review, 4 films were identified for review and analysis.

RESULTS

Themes that emerged from the analysis concerned the films' depictions of characters with pain, their healthcare providers, the therapies used for pain management, and the setting in which pain management was provided.

CONCLUSIONS

This study demonstrates that patients with cancer pain are depicted in a compassionate manner. Pain management focused on the use of opioids. The settings in which patients received pain management was depicted as not being amenable to providing holistic care. This variety of topics related to pain management covered in the films make them amenable to use in cinemeducation. This study therefore forms the basis for future work developing film-based cancer education modules.

Palliative Care in 2020 & Beyond Workshop: an expert symposium to develop palliative care advocacy in Turkey

BACKGROUND

In 2014, the World Health Assembly called for improved access to palliative care (PC) as a core component of healthcare systems. Still, in 2019 the development of PC activism in Turkey was patchy in scope, care provision is isolated and services are limited in relation to population size. This workshop was aimed to increase understanding of the PC approach in cancer and to discuss holistic strategies for implementing PC for cancer in Turkey.

METHODS

The workshop hosted in February 2020 at Ankara was attended by 80 healthcare professionals, bureaucrats, and international PC experts. Panel discussions were held to determine the current status, shortcomings and specify solutions for future PC in cancer in Turkey.

RESULTS

Positive developments in PC after 2010 were acknowledged. Yet PC services are insufficient and mostly unavailable in the less developed regions. PC centers embedded in oncology hospitals were run by oncologists and follows classical cancer treatment protocol. It has emerged that the future need for specialized pc will be greater than anticipated. The latest regulations and the National Pallia-Turk project will provide a framework to develop nationwide PC activism. The barriers are; limited training, lack of integration into cancer care, public ignorance, and legislative issues to Do-Not-Resuscitate (DNR) orders. The contextual suggestions are; all healthcare workers must acquire a minimum knowledge and skills of PC. Home-based PC should be timely and responsive, coordination among patient's care stakeholders, Hospital-based PC for intensive symptom control or reduce caregiver burden. simultaneous cancer and PC to avoid late referral, legal arrangements for advance directives and DNR orders, and public awareness via mass media initiatives.

SIGNIFICANCE OF RESULTS

The workshop recommendation substantially contributes to the existence of PC policy and guidelines; will be useful for the development of comprehensive PC activism to address the future need of PC in Turkey.

Progress in palliative care for cancer in Turkey: a review of the literature

BACKGROUND

The demographic transition in Turkey is shifting the burden of diseases towards non-communicable diseases including cancer. Palliative care (PC) as a component of Universal Health Coverage assures patient and family-centred care provision throughout the spectrum of cancer.

OBJECTIVES

This study aimed to make a detailed evaluation of the progress achieved since the mid-90s and the current situation of cancer PC in Turkey.

METHODS

A literature review was conducted in PubMed, Scopus, Embase, ScienceDirect, Web of Science, Google Scholar, The Turkish Academic Network and Information Centre databases, Ministry of Health documents, Council of Higher Education's thesis 01/1995 to 07/2020. The information was categorised into the six domains: history of the cancer PC; law and regulations; education and research; opioid use; patient care and palliative centres; public awareness, psychosocial support and end of life ethics.

RESULTS

Of 27,489 studies, 331 met the inclusion criteria. The majority were published in the Turkish language and were journal articles. The findings showed that the development of PC in Turkey can be divided into three stages: early initiatives before 2000, the dissemination stage, 2000-2010 and the advanced stage after 2010. There is evidence of progress in terms of legal regulations, opioid use and number of PC services and research output. However, there is still a need for improvement in professional education, public awareness and end of life care.

CONCLUSION

There is evidence of progress, barriers and opportunities. However, bringing research into practice is needed for scale-up and integration of PC in cancer care in Turkey.

Assessing Medical Students' Confidence towards Provision of Palliative Care: A Cross-Sectional Study

Under a surging demand for palliative care, medical students generally still show a lack of confidence in the provision in abroad studies. This cross-sectional study aims to investigate the confidence and its association with knowledge, attitude and exposure on providing palliative care among medical undergraduates with a self-administered questionnaire to improve the international phenomenon. Full-time local medical undergraduates were recruited to obtain information regarding the demographics, confidence, knowledge, attitude and exposure on palliative care; the information was collected from July 2020 to October 2020. Questions on confidence (10-items), knowledge (20-items), attitude (10-items) and exposure were referenced from validated indexes and designed from literature review. Confidence level was categorized into “Confident” and “Non-confident” as suggested by studies to facilitate data analysis and comparison. Of the 303 participants, 59.4% were “Non-confident” (95% C.I.: 53.8% to 65.0%) in providing palliative care on average. Among medical students, knowledge (p = 0.010) and attitude (p = 0.003) are significantly positively associated with the confidence to provide palliative care, while exposure to death of family/friends (p = 0.024) is negatively associated. This study begins an investigation on the research area in Hong Kong primarily. The confidence of local medical students should be enhanced to provide palliative care in their future. It thus highlights the importance of the medical curriculum and provides insights to remove barriers responsively to improve the overall confidence and the quality of palliative care.

Euthanasia and physician-assisted suicide: a systematic review of medical students' attitudes in the last 10 years

This study aimed at examining the approval rate of the medical students’ regarding active euthanasia, passive euthanasia, and physician-assisted-suicide over the last ten years. To do so, the arguments and variables affecting students’ choices were examined and a systematic review was conducted, using PubMed and Web of Science databases, including articles from January 2009 to December 2018.

From 135 identified articles, 13 met the inclusion criteria. The highest acceptance rates for euthanasia and physician-assisted suicide were from European countries. The most common arguments supporting euthanasia and physician-assisted suicide were the followings: (i) patient’s autonomy (n = 6), (ii) relief of suffering (n = 4), and (ii) the thought that terminally-ill patients are additional burden (n = 2). The most common arguments against euthanasia were as follows: (i) religious and personal beliefs (n = 4), (ii) the “slippery slope” argument and the risk of abuse (n = 4), and (iii) the physician’s role in preserving life (n = 2). Religion (n = 7), religiosity (n = 5), and the attributes of the medical school of origin (n = 3) were the most significant variables to influence the students’ attitude. However, age, previous academic experience, family income, and place of residence had no significant impact.

Medical students' opinions on euthanasia and physician-assisted suicide should be appropriately addressed and evaluated because their moral compass, under the influence of such opinions, will guide them in solving future ethical and therapeutic dilemmas in the medical field.

Education is an important factor in end-of-life care: results from a survey of Brazilian physicians' attitudes and knowledge in end-of-life medicine

BACKGROUND

According to the Latin America Association for palliative care, Brazil offers only 0.48 palliative care services per 1 million inhabitants. In 2012, no accredited physicians were working in palliative care, while only 1.1% of medical schools included palliative care education in their undergraduate curricula. As a reflection of the current scenario, little research about end-of-life care has been published so that studies addressing this subject in the Brazilian setting are crucial.

METHODS

A cross-sectional study study conducted with students applying for the medical residency of the Federal University of São Paulo were invited to voluntarily participate in an anonymous and self-administered questionnaire survey. The latter included demographic information, attitudes, prior training in end-of-life care, prior end-of-life care experience, the 20-item Palliative Care Knowledge Test (PCKT) and a consent term.

RESULTS

Of the 3086 subjects applying for residency, 2349 (76%) answered the survey, 2225 were eligible for analysis while 124 were excluded due to incomplete data. Although the majority (99,2%) thought it was important to have palliative care education in the medical curriculum, less than half of them (46,2%) reported having received no education on palliative care. The overall performance in the PCKT was poor, with a mean score of 10,79 (± 3). While philosophical questions were correctly answered (81,8% of correct answers), most participants lacked knowledge in symptom control (50,7% for pain, 57,3% for dyspnea, 52,2% for psychiatric problems and 43,4% for gastrointestinal problems). Doctors that had already concluded a prior residency program and the ones that had prior experience with terminal patients performed better in the PCKT (p < 0,001). The high-performance group (more than 50% of correct answers) had received more training in end-of-life care, showed more interest in learning more about the subject, had a better sense of preparedness, as well as a higher percentage of experience in caring for terminal patients (p < 0,001).

CONCLUSIONS

Our study showed that Brazilian physicians lack not only the knowledge, but also training in end-of-life medicine. Important factors to better knowledge in end-of-life care were prior training, previous contact with dying patients and prior medical residency. Corroborating the literature, for this group, training showed to be a key factor in overall in this area of knowledge. Therefore, Brazilian medical schools and residency programs should focus on improving palliative training, especially those involving contact with dying patients.

Building a Medical Undergraduate Palliative Care Curriculum: Lessons Learned

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.

A National, Palliative Care Competency Framework for Undergraduate Medical Curricula

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.

Palliative care education in the undergraduate medical curricula: students' views on the importance of, their confidence in, and knowledge of palliative care

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.

Refining the Frommelt Attitude Toward the Care of the Dying Scale (FATCOD-B) for medical students: A confirmatory factor analysis and Rasch validation study

OBJECTIVE

Given the increasing number of patients requiring palliative care and the need for more professionals who are able to provide care for the dying comfortably, assessment of medical attitudes toward end-of-life care is becoming a key aspect of medical education. The present study aimed to establish whether the Frommelt Attitude Toward the Care Of the Dying, Form B (FATCOD-B) meets current psychometric standards of validity for an assessment tool in medical education.

METHOD

The participants were 200 undergraduate medical students. Since in a previous study the FATCOD-B was found to have a weak structure due to poor item validity, a refined version was proposed and tested in the present study. Confirmatory factor analysis and the Rasch model were employed to assess its dimensionality and psychometric properties.

RESULTS

The construct measured by the FATCOD-B continues to be misspecified. The tool has a two-dimensional structure. The first is well-structured and demonstrates appreciable measurement and discriminant capabilities. The second has low validity because its measurement capabilities are based on weakly correlated items.

SIGNIFICANCE OF RESULTS

Our results suggest that the FATCOD-B measures a two-dimensional construct and that only its first dimension is a robust measurement tool for use in medical education to evaluate undergraduates' attitudes about caring for the dying.

Undergraduate curriculum in palliative medicine at Tampere University increases students' knowledge

BACKGROUND

Education in palliative medicine (PM) at medical schools reveals wide variation despite the increasing importance of palliative care. Many universities present poor description of the benefits and detailed content of the total curriculum in PM. Using the recommendations of European Association for Palliative Care (EAPC) as a reference, we evaluated the content and outcomes of the curriculum in PM at the University of Tampere, Finland.

METHODS

We searched for a PM curriculum by examining the teaching offered by every specialty and compared it to EAPC recommendations. Students' knowledge was evaluated using a progress test over three consecutive years.

RESULTS

We found 53.5 teaching hours addressing PM issues, which exceeds the recommendation of the EAPC. Basics, symptom management, ethics, and communication skills were well established, while education in psychosocial/spiritual aspects, teamwork and self-reflection failed to reach the recommendations. Out of the maximum of 4.0, the progress test mean scores in PM among the third, fourth, fifth and sixth year students were 0.1 (SD 0.71), 0.69 (SD 1.28), 1.38 (SD 1.46) and 2.53 (SD 1.26), respectively (p < 0.001). This growing knowledge was associated with the timely increase in teaching provided through the PM discipline. In addition, the students who completed the optional PM course achieved better mean scores (2.66; SD 1.27) than the others (1.33; SD 1.43) (p < 0.001).

CONCLUSIONS

The curriculum in PM at the University of Tampere is integrated into the teaching of many disciplines and complied well with the EAPC recommendations. This education led to increasing knowledge in PM among medical students.

The contribution of undergraduate palliative care education: does it influence the clinical patient's care?

PURPOSE OF REVIEW

The aim of this 2-year systematic review is to understand how learner assessment and curriculum evaluation of education in palliative care is being undertaken and to examine whether current undergraduate education influences the clinical patient's care.

RECENT FINDINGS

Almost half of the 30 studies reviewed used a qualitative approach to evaluate learning experiences. Only three of them were controlled studies and a further one was a cohort study.When students openly express themselves, they agree that there is 'something' deep as regards the core or the essence of medical practice or nursing. They feel that they become better professionals and better prepared for the patients, not only in terms of end of life care, but also as regards care, irrespective of the phase of the disease.The inclusion of palliative care in undergraduate education is a way of providing knowledge, skill, and competences about palliative care (especially communication) and also improving attitudes toward caring in advanced disease and at the end of life. Different methods of experiential learning, even brief experiences, which bring students into close contact with palliative care clinical cases or patients, are providing better results.

SUMMARY

From research studies, there is only indirect evidence that palliative care training at university leads to better clinical care of patients. In the future, long-term cohort or controlled studies might answer that question.

Physicians' and Nurse Practitioners' Level of Pessimism About End-of-Life Care During Training: Does It Change Over Time?

CONTEXT

An enhanced understanding of trainee attitudes about end-of-life care is needed to inform interventions to improve clinician communication about dying and death.

OBJECTIVES

To examine changes in trainee pessimism about end-of-life care over the course of one academic year and to explore predictors of pessimism among residents, fellows, and nurse practitioners.

METHODS

We used baseline and follow-up surveys completed by trainees during a randomized controlled trial of an intervention to improve clinician communication skills. Surveys addressed trainee feelings about end-of-life care. Latent variable modeling was used to identify indicators of trainee pessimism, and this pessimism construct was used to assess temporal changes in trainee attitudes about end-of-life care. We also examined predictors of trainee pessimism at baseline and follow-up. Data were available for 383 trainees from two training programs.

RESULTS

There was a significant decrease in pessimism between baseline and follow-up assessments. Age had a significant inverse effect on baseline pessimism, with older trainees being less pessimistic. There was a direct association of race/ethnicity on pessimism at follow-up, with greater pessimism among minority trainees (P = 0.028). The model suggests that between baseline and follow-up, pessimism among younger white non-Hispanic trainees decreased, whereas pessimism among younger trainees in racial/ethnic minorities increased over the same period.

CONCLUSION

Overall, trainee pessimism about end-of-life care decreases over time. Pessimism about end-of-life care among minority trainees may reflect the influence of culture on clinician attitudes about communication with seriously ill patients. Further research is needed to understand the evolution of trainee attitudes about end-of-life care during clinical training.

Inadequacy of Palliative Training in the Medical School Curriculum

This report examines the literature on palliative training in the current medical school curriculum. A literature search was conducted to identify relevant articles. Physicians and medical students both report feeling that their training in end-of-life care and in palliative issues is lacking. The literature expresses concerns about the varied and non-uniform approach to palliative care training across medical schools. The authors recommend the development of more palliative training assessment tools in order to aid in the standardization of curriculum involving end-of-life care. In addition, increased exposure to dying patients will aid students in building comfort with palliative care issues. Such a goal may be accomplished through required clerkships or other similar programs.

Attitudes of Medical Students Toward the Care of the Dying in Relation to Personality Traits

Caring for dying patients requires specific attitudes. Medical students often feel unprepared to cope with issues related to end-of-life care. Little is known about the relationships between personality and attitudes toward the dying; consequently, it is difficult for medical educators to devise training that is best suited to prepare students for practicing palliative medicine. The study aimed to investigate the role of personality in predicting students’ attitudes toward the care of the dying. The study findings suggest a significant link between more self-directed and less harm-avoidant personality profiles and more developed attitudes toward the dying. Personality assessment in medical curricula is important, not merely to help teachers plan tailored training but also to foster in future doctors the propensity to develop a patient-centered practice.