Australian resident doctors want more palliative medicine education: a survey of attitudes and perceived needs

General practitioner residents and patients end-of life: involvement and consequences

BACKGROUND

The ageing of the population and the increased number of chronic diseases are associated with an increased frequency of end of life care in hospital settings. Residents rotating in hospital wards play a major part in their care, regardless of their specialty. General practitioner (GP) residents are confronted to such activities in hospital settings during their training. Our aim was to know how they feel about taking care of dying patients, as end-of-life care are very different from the clinical activity they are trained to.

METHODS

We surveyed all GP trainees of "Ile de France". The survey was made of 41 questions regarding advanced directives divided in 7 sections about patients' care, communication, mentoring and repercussion on personal life. The survey was done one time, during two pre-specified days.

RESULTS

525 residents (53.8%) accepted to fulfill the survey. 74.1% of the residents thought that palliative care could have been better. Possible ways of improvements were: a reduction of unreasonable obstinacy (or therapeutic overkill, two terms defined in French law as curative treatment without reasonable hope of efficiency) (59.6%), patient's (210 answers, 40%) and relative's communication (information of patients and relatives about the severity of the disease and risk of death) (199 answers 37.9%). Residents also reported a lack of knowledge regarding end-of-life care specific treatments (411 answers, 79.3%) and 298 (47.2%) wished for better mentoring. Those difficulties were associated with repercussion on their private life (353 answers, 67.2%), particularly with their close relatives (55.4%). Finally, 56.2% of trainees thought that a systematic psychologic follow up should be instituted for those working in "at risk" hospital settings.

CONCLUSION

Self-perception management of dying patients by GP resident emphasize their lack of training and supervision. The feeling of suboptimal care is associated with consequences on personal life.

Palliative Care Attitudes and Experiences among Resident Physicians at Historically Black Colleges and Universities

CONTEXT

Seriously ill Black patients receive lower quality palliative care than White patients. Equitable access requires palliative care skills training for all physicians. Historically Black Colleges and Universities (HBCUs) play a key role in educating Black physicians and have less access to palliative care resources.

OBJECTIVE

To investigate palliative care attitudes and experiences among primary care residents at HBCUs.

METHODS

Internal Medicine and Family Medicine residents at two HBCUs completed an online survey assessing attitudes towards palliative care and teaching and clinical experiences in palliative care. We performed a descriptive analysis of survey items.

RESULTS

Among 91 residents who completed the survey (response rate 48%), 65% were women and 68% Black. Most (96%) said that learning about palliative care was moderately/very important to their career; however, two-thirds of respondents considered care for dying patients to be depressing and half reported receiving negative messages about palliative care from other physicians. Residents reported receiving less teaching about providing palliative care (5.4 ± 2.3 on 10-point scale) than about managing sepsis (8.3 ± 1.8; P < 0.05). Fewer residents rated their palliative care education as "Excellent" or "Very Good" compared to their overall education (13% vs 70%; P < 0.05).

CONCLUSION

In the first survey exploring palliative care education at HBCUs, residents viewed palliative care as important but described the quality of their palliative care education as poor. This study highlights opportunities for improving palliative care education at HBCUs as a step toward addressing disparities in serious illness care.

Goals of Care Discussions Over the Course of a Patient's End of Life Admission: A Retrospective Study

BACKGROUND

As deaths in hospitals increase, clear discussions regarding resuscitation status and treatment limitations, referred to as goals of care (GOC), are vital. GOC may need revision as disease and patient priorities change over time. There is limited data about who is involved in GOC discussions, and how this changes as patients deteriorate in hospital.

AIMS

To review the timing and clinicians involved in GOC discussions for a cohort of patients who died in hospital.

METHODS

Retrospective observational audit of 80 consecutive end of life admissions between March 11th and April 9th, 2019.

RESULTS

Of 80 patients, 75 (93.6%) had GOC recorded during their admission, about half for ward-based non-burdensome symptom management or end-of-life care. GOC were revised in 68.0% of cases. Medical staff involved in initial versus final GOC discussions included home team junior doctor (54.7% versus 72.5%), home team consultant (37.3% versus 56.9%) and ICU doctor (16.0% versus 21.6%). For initial versus final GOC decisions, patients were involved in 34.7% versus 31.4%, and family in 53.3% versus 86.3%. Dying was documented for 92.0% of patients and this was documented to have been communicated to the family and patient in 98.6% and 19.5% of cases respectively.

CONCLUSIONS

As patients deteriorated, family and senior clinician involvement in GOC discussions increased, but patient involvement did not. Junior doctors were most heavily involved in discussions. We advocate for further GOC training and modeling to enhance junior doctors' confidence and competence in conducting and involving patients and families in GOC conversations.

Bereaved families' experiences of end-of-life decision making for general medicine patients

BACKGROUND

Family involvement in decision making for hospitalised patients is associated with improved end-of-life care. Yet, these discussions can be challenging for physicians and families and associated with distress, confusion and conflict. There is a need to understand how best to support families involved in decisions regarding the transition from active to palliative treatment in hospital settings.

AIM

To explore bereaved families' experiences of end-of-life decision making for general medicine patients.

DESIGN

A qualitative exploratory study framed by social constructionism using semistructured interviews and thematic analysis.

SETTING AND PARTICIPANTS

The general medicine units of one large public hospital in Melbourne, Australia. We recruited 28 bereaved family members of patients who had received end-of-life care.

FINDINGS

Patients and families depended on physicians to explain clinical complexity and treatment beneficence; however, trust in medical judgement was mediated by participant's own interpretations of clinical progress. Families sought to be respected as advocates and experienced distress if physicians disregarded their perspectives and insight concerning patient preferences. Ideally, families supported patients to express their preferences to physicians. Otherwise, families contextualised treatment decisions through their knowledge of patient's values and quality of life. Families often felt burdened by or excluded from medical decision making and experienced distress and confusion regarding their rights to request or refuse treatment.

CONCLUSION

Our study highlights how families contribute to decision making to ensure end-of-life care treatments reflect patient preferences. Physicians can ease families' distress around treatment withdrawal by providing a meaningful explanation of complex clinical issues, clarifying decision-making roles and acknowledge families' desire to protect and advocate for their loved one.

Palliative and end-of-life care and junior doctors': a systematic review and narrative synthesis

Background

Palliative and end-of-life care is a core competency for doctors and is increasingly recognised as a key clinical skill for junior doctors. There is a growing international movement to embed palliative care education in medical student and junior doctor education. To date there has been no review of the literature concerning the views and experiences of junior doctors delivering this care.

Aim

To review the published literature between 2000 and 2019 concerning junior doctors’ experience of palliative and end-of-life care.

Methods

Systematic literature review and narrative synthesis.

Results

A search of six databases identified 7191 titles; 34 papers met the inclusion criteria, with a further 5 identified from reference searching. Data were extracted into a review-specific extraction sheet and a narrative synthesis undertaken. Three key themes were identified: (1) ‘Significance of death and dying’: all papers found that junior doctors care for many patients approaching the end of life, and this often causes emotional distress and can leave persisting memories for many years afterwards; (2) ‘Thrown in at the deep end’: junior doctors feel unprepared and unsupported in providing palliative and end-of-life care; and (3) ‘Addressing the gaps’: junior doctors often experience a medical culture of disengagement towards dying patients and varying attitudes of senior doctors. Subsequently they have to learn the skills needed through seeking their own opportunities.

Conclusion

Medical education needs to change in order to better prepare and support junior doctors for their role in caring for dying patients. This education needs to focus on their knowledge, skills and attitudes.

Junior doctors' attitudes to opioids for refractory breathlessness in patients with advanced chronic obstructive pulmonary disease

BACKGROUND

Refractory breathlessness is a common, distressing symptom in patients with advanced chronic obstructive pulmonary disease (COPD). The judicious, off-licence prescription of opioids, together with other management strategies, can improve breathlessness, however, internationally there is profound reluctance to prescribe opioids for breathlessness in COPD.

AIMS

To understand Australian junior doctors' knowledge and attitudes regarding the management of refractory breathlessness and the role of opioids in COPD.

METHODS

All junior doctors undertaking basic training in internal medicine in Victoria were invited to complete an online survey. Knowledge, willingness, and experience prescribing opioids to COPD patients with refractory breathlessness, were examined.

RESULTS

Of the 243 responses received, most trainees (193, 86.5%) believed opioids have a role in treating refractory breathlessness in stable COPD outpatients, with 143 (64.1%) recommending morphine as first-line treatment for refractory breathlessness. One quarter (55, 24.7%) reported having themselves initiated an opioid and 102 (45.7%) had prescribed an opioid under senior supervision for management of breathlessness in COPD. Concern regarding adverse opioid effects was low, with 58 (26.0%) having no concerns prescribing an opioid to COPD patients.

CONCLUSION

This is the first study of doctors to demonstrate high awareness, confidence, willingness and experience in prescribing opioids for the off-licence indication of refractory breathlessness in COPD. These findings differ significantly from attitudes reported overseas and are unexpected given the doctors surveyed were recently qualified. The low awareness of possible adverse events and limited insight regarding knowledge gaps is concerning and highlights the significant need for greater education in palliative care.

Development and Initial Psychometric Properties of a Questionnaire to Assess Competence in Palliative Care: Palliative Care Competence Framework Questionnaire

Background:

Although the provision of palliative care (PC) is fundamental to the role of the physician, little research has assessed the competence of trainee and experienced physicians in PC.

Aim:

To describe the development of a competence questionnaire and assess the level of competence of medical doctors in Ireland to provide PC to individuals with life-limiting conditions and their families.

Design:

A survey-based cohort study was employed using a questionnaire based on the Palliative Care Competence Framework, developed specifically for this study.

Setting:

The sample was accessed via the Royal College of Physicians of Ireland. All specialties in adult medical care and direct patient contact were included.

Results:

A pilot study demonstrated comprehensiveness and ensured face validity. In the main study, all subscales showed internal reliability and evidence of a normal distribution. Strong correlation was noted between knowledge and behavior while moderate correlations were noted between attitudes and behavior and attitudes and knowledge, respectively. As expected, palliative-trained participants scored significantly higher in attitudes, behavior, and knowledge.

Conclusions:

The study provides baseline data on the level of competence of PC of doctors working in Ireland. The study also offers a novel assessment tool that has the potential to be used for future research.

A survey of views and opinions of health professionals managing thirst in chronic heart failure

BACKGROUND

Thirst is a common and burdensome symptom of chronic heart failure (CHF) which affects adherence to self-care practices specifically fluid restriction. Despite this, there is no standard clinical practice for managing the symptom of thirst.

AIMS AND OBJECTIVES

The aim is to identify the current strategies recommended by health professionals to help relieve thirst in CHF patients and their perceived usefulness of these strategies.

METHODS

A survey was distributed to attendees of the 8th Annual Scientific Meeting of Australasian Cardiovascular Nursing College.

RESULTS

There were 42 of 70 respondents to the survey. The majority (33 of 40; 82.5%) had recommended various strategies to alleviate thirst. The most recommended strategy was ice chips (36 of 38; 94.7%). Overall, the respondents reported 'some use' in all of the strategies.

CONCLUSION

Information from this survey may help in the incorporation of thirst-relieving strategies into evidence-based guidelines; further improving the quality of care of patients.