End-of-life and palliative care education in US pharmacy schools

Death and dying in pharmacy learners: A critical review

PURPOSE

This review article is the first comprehensive evaluation of the available literature surrounding the education of death and dying in pharmacy schools. The purpose of this review was to describe the available literature and methods utilized regarding the emotional preparation for patient death in pharmacy education.

PROCEDURES

Searches were performed in three pharmacy databases to identify articles that contained descriptions of activities related to death and dying education in pharmacy curriculums.

FINDINGS

Eleven journal articles were reviewed, detailing activities in pharmacy education including simulations, didactic sessions, and an innovative "death over dessert" model. Evaluation methods varied, with surveys being most common, followed by reflection. Didactic courses demonstrated increased empathy and knowledge, while simulations compared to case-based activities improved skills, knowledge, and comfort levels with providing end-of-life care. Simulations often involved interprofessional groups, with third-year pharmacy students most evaluated.

CONCLUSION

Pharmacy students were mainly exposed to death and dying scenarios through didactic courses or simulations, with limited longitudinal exposure. Research suggests that students may lack preparation for handling death-related situations, leading to trauma and dysfunction. While existing studies focus on outward effects like empathy, internal factors such as coping methods receive less attention. Unlike nursing and medicine literature, pharmacy education lacks comprehensive coverage of coping and emotional support strategies for death and dying scenarios. Additional focus should be placed on intentional incorporation of these topics into pharmacy curriculums.

Safely gaining experience in death and dying: Simulation in palliative care and end-of-life education

BACKGROUND

Training in palliative and end-of-life (EOL) care provision represents a critical topic in health professional curricula for ensuring a workforce prepared to provide safe and person-center care at the end of one's life. This manuscript describes the incorporation of a simulation-based learning experience (SBLE) and the evolution of a professional elective course for student pharmacists related to palliative and EOL care.

EDUCATIONAL ACTIVITY

A SBLE was incorporated into a long-standing professional pharmacy elective course in palliative and EOL care. The decision to incorporate and utilize SBLE to introduce topics of deprescribing, communication, prioritization of quality of life, and establishing goals of care was utilized in recognition of a need to establish a psychologically safer environment to allow students to explore these topics prior to the advanced pharmacy practice experiences.

DISCUSSION

Incorporation of SBLE in this professional elective course resulted in a favorable effect on course enrollment. Observations from structured debriefing and anecdotal student feedback suggest that students had trouble tailoring care plans to the circumstances, particularly in focusing on de-escalating medication treatments, emphasizing the need for training in the care for this patient population which incorporate considerations for goals of care. Lessons related to the influence of environmental distractions, expressions of discomfort conveyed by body language, and challenges in prioritizing and focusing on tailoring care plans given evolving information at hand were identified.

IMPLICATIONS

We describe the effective implementation and utilization of SBLE in a professional elective focused on palliative and EOL care for student pharmacists. Future directions include research initiatives designed to evaluate the impact of simulation on key competencies and areas developed through participation in such exercises. Systematic evaluation of outcomes and competencies related to team dynamics, sympathetic communication, professional identity formation and resiliency and preparation for dealing with death and dying in experiential learning are planned.

Some Reflections On The History And Current Status of Education in the Field of Death, Dying, and Bereavement at the College and University Level In North America

This article is a contribution to recording one dimension of the field of death, dying, and bereavement. It offers some personal reflections on the history and current status of formal education in this field at the college and university level in North America. The scope of this reflection looks back on the earliest known examples of formal education in this field that took place in the 1960s and 1970s, provides examples of some of the early pedagogical resources that were created to support and foster those initiatives, and sketches more recent developments as regards introductory or undergraduate survey courses in this field, other death-related courses, programs in thanatology, and efforts to offer certificates or certification for educators and other professionals in this field. The article concludes with some thoughts about what we have learned from and about education in the field of death, dying, and bereavement.

One School of Pharmacy's Experience of Talking With Student Pharmacists About Coping With Patient Death

OBJECTIVE

End-of-life care is an important aspect of health care profession education; however, little has been published about preparing student pharmacists for the emotional impact of their patient dying. This manuscript describes using a question-and-answer seminar with a mixed faculty and student panel, members of which had been impacted by a patient's death, as a stimulus for student reflection on how they might cope in similar circumstances.

METHODS

Students attending the seminar were provided a guiding prompt for reflecting on what would help them respond to a patient's death. The resulting essays were analyzed for 5 themes inspired by the guiding prompt, and categories of responses for each theme were created using an inductive approach. Descriptive statistics were used to analyze the results.

RESULTS

A total of 69 student pharmacists submitted essays and 552 statements were identified and coded into 5 themes and 23 categories. The most commonly addressed theme was "personal strategies" for coping with loss, whereas the least addressed was "resources" available to pharmacists. The most commonly mentioned strategies were "acknowledge your emotions" and "talk with others."

CONCLUSION

A simple-to-implement seminar was effective at stimulating student reflection on how they would cope with a patient's death. Although some students had already experienced the death of a patient, others stated they had never considered that their patients may die, supporting the importance of the panel discussion.

Development and validation of a performance-based palliative care assessment tool for student pharmacists

INTRODUCTION

Integration of hospice and palliative care principles within pharmacy curricula is essential to fill the need of pharmacist training in this growing specialty. A formalized assessment tool to evaluate skill development does not exist for student pharmacists specific to palliative care. The objective of this study was to develop a valid and reliable, palliative care-focused, performance-based assessment tool for student pharmacists.

METHODS

Eight academic palliative care (PC) pharmacists were recruited for the workgroup to perform domain development, validation, tool creation, and reliability testing for this performance-based assessment tool. Hospice and palliative care clinical pharmacist entrustable professional activities (EPAs) served as the framework. Content validity testing utilized content validity index and scale universal agreement (S-CVI/UA) to determine level of agreement for activities included in the tool. Student volunteers completed a standardized patient case and workgroup members served as raters during the reliability testing phase. Interrater reliability was measured through calculation of Fleiss Kappa scores for each activity.

RESULTS

Out of 14 EPAs, nine were deemed "essential" to include in the tool. Thirty-four supporting activities for the nine essential EPAs were drafted. Two rounds of content validity testing were necessary to achieve S-CVI/UA of 0.9593. Consensus was reached from workgroup members for activities deemed necessary to include in the tool after questionnaire distribution utilizing a Fleiss Kappa cutoff >0.6.

CONCLUSIONS

This validated tool will afford colleges and schools of pharmacy with PC curricula an opportunity to assess student achievement of PC-specific skills and evaluate curricular effectiveness.

Development of Entrustable Professional Activities for Specialist Hospice and Palliative Care Pharmacists

CONTEXT

Entrustable professional activities (EPAs) translate competencies into explicit, practical terms that clearly state the expected roles and responsibilities of clinicians who have achieved proficiency and expertise in a field. EPAs are defined for Hospice and Palliative Medicine physicians but not for other members of Hospice and Palliative Care (HAPC) interprofessional teams, including pharmacists.

OBJECTIVES

The objective of this study was to develop EPAs for HAPC pharmacists.

METHODS

An 11-member workgroup of HAPC pharmacists was convened to develop candidate EPAs using nominal group and modified-Delphi methods. Content validity index was used as a measure of consensus, defined a priori at ≥ 60%. Vetting occurred via intra- and interprofessional stakeholder reactor groups and a national survey of HAPC pharmacists.

RESULTS

Following an iterative process of workgroup and stakeholder consensus-building, 15 HAPC pharmacist EPAs were developed. Among the workgroup, all 15 EPAs reached ≥ 70% consensus, indicating appropriate internal validity. In a national survey of 185 HAPC pharmacists with a 20% response rate, 13 EPAs were rated by most respondents as "essential" and 2 were rated by most respondents as "important but not essential." Respondents indicated the 15 EPA set represented the core professional activities of HAPC pharmacists well (median rating of 5 on a Likert-like scale, IQR 1).

CONCLUSION

Fifteen consensus EPAs describe essential activities of HAPC pharmacists in direct patient care, leadership, education, and scholarship. These EPAs will further guide pharmacist training programs, HAPC services seeking to incorporate a specialized pharmacist on the team, and currently practicing HAPC pharmacists.

The Role of an Inpatient Hospice and Palliative Clinical Pharmacist in the Interdisciplinary Team

Palliative care is a specialized health care service for individuals with serious illness at any stage and can be provided in any setting. Current national consensus developed by palliative care experts recommends the inclusion of pharmacists in an interdisciplinary team (IDT) to provide quality palliative care. However, national registry data report that less than 10% of inpatient palliative teams in the U.S. have a clinical pharmacist. Clinical pharmacists have an impactful role in palliative patients' quality of life by optimizing symptom management, deprescribing, and providing education to the palliative care team as well as patients and their families. In this report, we review the current literature on the role of a palliative pharmacist in an inpatient palliative care setting and compare and contrast this with our own clinical practice, providing case examples about the role of a palliative clinical pharmacist in an interdisciplinary inpatient palliative care setting. Future strategies are needed to increase post-graduate specialized pharmacy residency training in palliative care as well as education on palliative and hospice care in pharmacy schools to support the role of clinical pharmacists in palliative care.

"Death Over Dessert" - A conversation with pharmacy students about what really matters in the end

BACKGROUND AND PURPOSE

Pharmacists will encounter the death of patients and loved ones throughout their career. Though this is a part of our profession as health care providers, many pharmacy students express discomfort and even fear of discussing death and dying with their patients. "Death Over Dessert" has been developed as a loosely structured discussion held during a required geriatrics advanced pharmacy practice experience (APPE). EDUCATIONAL ACTIVITY AND SETTING: "Death Over Dessert: uses principles of "Death Over Dinner," a free online program, "Where I Stand" scales from The Conversation Project, and a series of written reflection questions for after the activity. The discussion is led by two faculty members and ranges from two to six APPE students per offering. A mixed-methods approach was used to assess participant responses to reflection questions.

FINDINGS

Of the 19 participants, all (n = 19, 100%) found the activity to be beneficial despite many mentioning the topic can be uncomfortable. There were five overall themes identified that broached personal and professional views: significance of end-of-life discussion with family, important aspects of personal wishes at end-of-life, the definition of living, approaches to end-of-life discussion, and the role of end-of-life in the pharmacy curriculum.

SUMMARY

"Death Over Dessert" is a new teaching modality for faculty and preceptors to consider using in their classrooms or rotation activities.

Effect of death and dying elective on student empathy and attitudes toward mortality

INTRODUCTION

Pharmacy graduates should be equipped for one inevitable aspect of health care, mortality, yet only 10% of United States pharmacy curricula courses cover end-of-life (EoL) with limited evidence of effectiveness. This study's objective was to evaluate the impact of an EoL elective on student pharmacists' empathy and attitudes toward mortality and caring for terminally ill persons.

METHODS

First- through third-year student pharmacists enrolled in an EoL elective. Students completed pre- and post-course surveys on self-perceptions of empathy and mortality. Surveys included the following: Kiersma-Chen Empathy Scale (KCES), which assesses empathy of pharmacy and nursing students; revised Collett-Lester Fear of Death and Dying Scale (CL-FODS), which measures fear related to death; and Frommelt Attitudes Toward Care of the Dying Scale Form B (FATCOD-B), which measures health care professionals' attitudes toward EoL care. Anonymous identifiers were used to link pre- and post-course surveys and were collected with an online survey software. Data were analyzed using two-sided paired t-tests.

RESULTS

Twenty-seven student pharmacists completed the elective. The change in overall mean scores for KCES, CL-FODS, and FATCOD-B correlated with increased empathy, reduced fear of death, and increased positive attitudes toward caring for terminal patients (KCES pre-course = 86.15 vs. post-course = 90.37; CL-FODS pre-course = 93.70 vs. post-course = 75.15; FATCOD-B pre-course = 115.89 vs. post-course = 124.04).

CONCLUSIONS

After the EoL elective, student empathy and attitudes toward mortality and caring for terminally ill persons improved. Implementing EoL concepts in pharmacy curricula should be explored to better prepare graduates in patient care.

A Systematic Review of Palliative Care Content in the Doctor of Pharmacy Curriculum

Objective. To describe the methods of teaching and evaluating palliative care experiences for pharmacy students.Findings. A literature search retrieved 971 reports, from which 26 studies met all of study criteria. Educational interventions concerning palliative care included didactic courses, flipped classrooms, advanced pharmacy practice experiences (APPEs), workshops, and seminars. Total direct hours of education in palliative care ranged from 1-200. Seven (27%) focused experiences were reported as required, while nine (35%) were reported as elective. The majority (n=14, 54%) of studies measured pharmacy students' confidence, attitudes, or perceptions as the main outcome, and of those most studies reported an improvement. Five (19%) studies reported on interprofessional experiences in palliative care conducted in the United States, and four (15%) studies reported on similar experiences conducted outside the United States. When reported, most experiences were developed for students to complete prior to beginning their APPE year. All of the included studies used a non-randomized design.Summary. This review suggests a palliative care experience for pharmacy students should be interprofessional, occur during the year prior to APPEs, and measure skills-based outcomes.

The Need for Palliative Care in Pharmacy Education

There is a growing need for palliative care pharmacists in the United States. There is also a gap in the education of palliative care for pharmacy students. To address both, pharmacy schools must develop and disseminate palliative care-focused experiences, including traditional didactic lectures, problem-based learning, interactive skills, laboratory- and web-based experiences. This commentary presents the need for palliative care-focused experiences in the Doctor of Pharmacy (PharmD) degree program, and how schools can take smaller steps to tackle this issue.

Palliative and end of life care content within common pharmacy textbooks

INTRODUCTION

This study compared the end-of-life care (EOLC) content in pharmacy-related textbooks to textbooks evaluated in a comparable 2003 study.

METHODS

Six common pharmacy-related textbooks were reviewed for content relating to EOLC. Five of the textbooks were the newest editions of the same texts reviewed in a similar 2003 study, and one focused primarily on clinical ethics, a topic that was underrepresented in the previous study. The six texts were searched for a list of 33 keywords or phrases pertaining to EOLC. Entries containing any of these 33 keywords were assigned a domain and scored using a simple scoring system of one if minimally helpful content was present or two if helpful content was present. The total number of entries and their average scores were compared to the results of the previous study.

RESULTS

The average number of entries per textbook was 154, which represents an increase from the 110.1 average number of entries in the 2003 study. However, one of the textbooks had a total of 470 entries alone. Of a total number of 78 possible domains, 40 had either zero or one entries. The average ratings for each book ranged from 0.5 to 1.6, whereas they ranged from 0.9 to 1.6 in 2003. Four of six books in this study had average rating of less than 0.9.

CONCLUSION

Although certain texts have made strides to include more EOLC content, overall, EOLC content in pharmacy textbooks may still be improved.

A qualitative exploration of perceived key knowledge and skills in end-of-life care in dementia patients among medical, nursing, and pharmacy students

BACKGROUND

The steady increase in the number of people living and dying with dementia, coupled with the recent focus on quality of care, has highlighted the importance of dementia training for health care professionals. This exploratory study aimed to discover which skills health care students felt were important in providing quality end-of-life care to dementia patients.

METHODS

Ninety-four medicine, nursing, and pharmacy students participated in a larger study using open-ended and closed questions to explore attitudes related to caring for dementia patients at the end of life. This study looks at the student responses to an open-ended question regarding the skills and knowledge they believe are needed to provide end-of-life care to dementia patients. Individual responses were reviewed by the researchers, coded into key issues, and tabulated for frequency of occurrences and group differences.

RESULTS

Several common issues emerged: knowledge, patience, empathy, understanding, family involvement, compassion, medication knowledge, respect/patient autonomy, communication, quality of life, and patient education. Significant differences were observed among the participant groups on the following issues: Patience and understanding (pharmacy students mentioned these issues less frequently than medical and nursing students), compassion (medical students mentioned this issue more frequently than pharmacy students), and medication knowledge (pharmacy students mentioned this issue more frequently than medical and nursing students).

CONCLUSIONS

Different health care disciplines (in-training) value different skill sets for the provision of dementia care at the end-of-life. As health care education for dementia patients at the end of life is expanded, it will be important to understand which skills both patients and health care students value.

End-of-Life and Palliative Care Curricula in U.S. Social Work Graduate Programs

Social workers have a high probability of relating to clients with terminal illnesses and their families. Yet, end-of-life education in U.S. graduate programs of social work has been somewhat limited. A recent guideline by the National Association of Social Workers (NASW) sets standards for social work practice in palliative and end-of-life care. This article presents the results of a 2012 survey of U.S. social work graduate programs to determine curricula offerings in end-of-life and palliative care. Results suggest that the majority of graduate social work programs are addressing the NASW guidelines; however, less than half of students participate in the offering(s).