Primary care physicians' educational needs and learning preferences in end of life care: A focus group study in the UK

Perceived Palliative Care Education Needs of GP Trainees: A National Study

CONTEXT

GP's provide palliative care in the community. Managing complex palliative needs can be challenging for GPs and even more so for GP trainees. During the postgraduate training period GP trainees are working in the community but have more time for education. This time in their career could present a good opportunity for palliative care education. For any education to be effective their educational needs must first be clarified.

OBJECTIVES

To explore the perceived palliative care education needs and preferred education methods of GP trainees.

METHODS

A national, multisite qualitative study involving a series of semistructured focus group interviews with third and fourth year GP trainees. Data were coded and analyzed using Reflexive Thematic Analysis.

RESULTS

Perceived Educational Needs: five themes were conceptualized: 1) Empowerment vs. Disempowerment; 2) Community Practice; 3) Intra- and Interpersonal Skills; 4) Formative Experiences; 5) Contextual Challenges.

PREFERRED EDUCATIONAL METHODS

Three themes were conceptualized: 1) Oriented Learning-experiential vs. didactic; 2) Practicalities; 3) Communication Skills.

CONCLUSION

This is the first multisite national qualitative study exploring the perceived palliative care educational needs and preferred educational methods of GP trainees. Trainees expressed a unanimous need for experiential palliative care education. Trainees also identified means to address their educational requirements. This study suggests that a collaborative approach between specialist palliative care and general practice is necessary to create educational opportunities.

Using Social Constructivist Learning Theory to Unpack General Practitioners' Learning Preferences of End-of-Life Care: A Systematically Constructed Narrative Review

General practitioners play a vital role in providing community-based palliative care to patients reaching end of life. In order for GPs to upgrade their skills at end-of-life care delivery, it is imperative that training programs be aligned to their learning needs and preferences. A narrative review was conducted using the electronic databases PubMed, CINAHL, PsycINFO, EMBASE, Scopus, Web of Science, and Cochrane from 01/01/1990 to 31/05/2021. 23 articles (of 10037 searched) were included for the review. Following themes were generated: Value attributed to end-of-life care learning, experience and reflection as a departure point for learning, learning as embedded in the clinical context; autonomy to decide upon their learning needs and learning preferences, learning as a transformative process; and learning as embedded in social interaction and interpretation. Training programs that are aligned to the preferences of GPs will encourage a larger clientele of GPs to access them.

Physician Perceptions and Beliefs Regarding End-of-Life Care in a Central California Health System

Objective: We sought to describe the preparedness, beliefs, and experience regarding end-of-life (EOL) care for in-training and attending physicians. We hoped to clarify how medical training impacts views about EOL, and topics where physicians desire more EOL training. Methods: An online anonymous survey was sent to 766 physicians who worked at Community Medical Centers in Fresno, California from October to December 2016. Descriptive statistics of the population were compiled. Chi-squared and Mann-Whitney U tests comparing differences in personal experience, and preparedness and confidence with palliative care topics by training level were performed. Results: 195 physicians responded to the survey (25%). Respondents were 42% in-training, 55% male, 57% Caucasian, and 38% Christian. Compared to attendings those in-training were younger, more often female, and more likely to have a DO degree. The 2 groups did not differ in ethnicity, specialty, or religion. Attendings were more likely than those in-training (46% vs 14%, P < .001) to have an advance directive, reported a higher level of formal training in discussing prognosis (P = .037), and had higher confidence with palliative care topics like delivering bad news (P = .002), discussing resuscitation status (P = .015), and discussing the new California EOL Option Act (P < .001). Thirty-two percent of respondents believed patients often starve at EOL. Otherwise, knowledge was 90% correct. Conclusions: Physicians in-training are less prepared to discuss EOL topics. Physicians in-training and attendings desire more education in pain management at EOL.

Role and response of primary healthcare services in community end-of-life care during COVID-19: Qualitative study and recommendations for primary palliative care delivery

BACKGROUND

The need for end-of-life care in the community increased significantly during the COVID-19 pandemic. Primary care services, including general practitioners and community nurses, had a critical role in providing such care, rapidly changing their working practices to meet demand. Little is known about primary care responses to a major change in place of care towards the end of life, or the implications for future end-of-life care services.

AIM

To gather general practitioner and community nurse perspectives on factors that facilitated community end-of-life care during the COVID-19 pandemic, and to use this to develop recommendations to improve future delivery of end-of-life care.

DESIGN

Qualitative interview study with thematic analysis, followed by refinement of themes and recommendations in consultation with an expert advisory group.

PARTICIPANTS

General practitioners (n = 8) and community nurses (n = 17) working in primary care in the UK.

RESULTS

General practitioner and community nurse perspectives on factors critical to sustaining community end-of-life care were identified under three themes: (1) partnership working is key, (2) care planning for end-of-life needs improvement, and (3) importance of the physical presence of primary care professionals. Drawing on participants' experiences and behaviour change theory, recommendations are proposed to improve end-of-life care in primary care.

CONCLUSIONS

To sustain and embed positive change, an increased policy focus on primary care in end-of-life care is required. Targeted interventions developed during COVID-19, including online team meetings and education, new prescribing systems and unified guidance, could increase capacity and capability of the primary care workforce to deliver community end-of-life care.

Views of general practitioners on end-of-life care learning preferences: a systematic review

Background

General practitioners (GPs) play a pivotal role in providing end-of-life care in the community. Although they value end-of-life care, they have apprehensions about providing care in view of the limitations in knowledge and skills in end-of-life care. This review aimed to explore, synthesise, and analyse the views of general practitioners on end-of-life care learning preferences.

Methods

MEDLINE, CINAHL, PsycINFO, EMBASE, Scopus, Web of Science, and Cochrane were searched for literature on the views of general practitioners on end-of-life care learning preferences from 01/01/1990 to 31/05/2021. Methodological quality was reported.

Results

Of the 10,037 articles identified, 23 were included for the review. Five themes developed from the review. The desire to provide palliative care, as well as self-actualisation needs, relevance to practice, a sense of responsibility, and a therapeutic bond, motivates general practitioners to learn end-of-life care. Some of the learning needs expressed were pain and symptom management, communication skills, and addressing caregiver needs. Experiential learning and pragmatist learning styles were preferred learning styles. They perceived the need for an amicable learning environment in which they could freely express their deficiencies. The review also identified barriers to learning, challenges at personal and professional level, feelings of disempowerment, and conflicts in care.

Conclusion

GPs’ preference for learning about end-of-life care was influenced by the value attributed to learning, context and content, as well as preference for learning styles and the availability of resources. Thus, future trainings must be in alignment with the GPs’ learning preferences.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12904-022-01053-9.

Challenges in eating disorder diagnosis and management among family physicians and trainees: a qualitative study

BACKGROUND

Family physicians are one of the first points of contact for individuals with eating disorders (EDs) seeking care and treatment, but training in this area is suboptimal and insufficient. Specialized ED treatment programs often have long wait lists, and family physicians are responsible for patients care in the interim. The aim of this study was to identify the learning needs and challenges faced by Canadian family physicians and trainees when caring for patients with EDs.

METHODS

We recruited six family medicine residents and five family physicians practicing in an academic unit in the Department of Family Medicine of a medical school in urban southwestern Ontario, Canada. We used purposive sampling, focusing on residents and faculty physicians from the department and conducted one focus group for the residents and another for the faculty physicians, exploring their clinical knowledge and challenges when managing ED patients. The focus groups were audio-recorded and transcribed verbatim prior to thematic coding.

RESULTS

Physicians and residents faced challenges in discussing, screening, and managing patients with EDs. Three themes that emerged from the qualitative data highlighted training needs related to: (a) improving communication skills when treating a patient with an ED, (b) more effective screening and diagnosis in primary care practice, and (c) optimizing management strategies for patients with an ED, especially patients who are waiting for more intensive treatment. A fourth theme that emerged was the distress experienced by family physicians as they try best to manage and access care for their patients with EDs.

CONCLUSION

Addressing the learning needs identified in this study through continuing education offerings could aid family physicians in confidently providing effective, evidence-based care to patients with EDs. Improvement in training and education could also alleviate some of the distress faced by family physicians in managing patients with EDs. Ultimately, system changes to allow more efficient and appropriate levels of care for patients with EDs, removing the burden from family medicine, are critical as EDs are on the rise. A person with an eating disorder will normally seek care from their family physician first. These conditions can dramatically reduce the quality of a person's life and health. Family physicians therefore need to know how best to help these patients or refer them to a more intensive level of care, which often has long wait lists. We asked a group of family physicians and a group of family medicine trainees about their experiences with patients with eating disorders and about the information they wished they had to help these patients. The results show that they need more information on how to talk to a patient about eating disorders without judgement, how to diagnose a patient with an eating disorder, and then what treatment and management is needed while they wait for more intensive treatment for sicker patients. The physicians and trainees both talked about the stress and worry that they faced when treating patients with eating disorders. Besides their lack of training about these conditions, family physicians also described difficulties when trying to access timely specialized services for their patients. Physicians can experience moral distress when they know that their patients need higher level care, but there are systemic barriers to specialized programs that block their patients from getting the care they need when they need it.

Development and Early Experience of a Primary Care Learning Collaborative in a Large Health Care System

Introduction:

Primary care clinicians are presented with hundreds of new clinical recommendations and guidelines. To consider practice change clinicians must identify relevant information and develop a contextual framework. Too much attention to information irrelevant to one’s practice results in wasted resources. Too little results in care gaps. A small group of primary care clinicians in a large health system sought to address the problem of vetting new information and providing peer reviewed context. This was done by engaging colleagues across the system though a primary care learning collaborative.

Methods:

The collaborative was a grass roots initiative between community and academic-based clinicians. They invited all the system’s primary care clinicians to participate. They selected new recommendations or guidelines and used surveys as the principal communication instrument. Surveys shared practice experience and also invited members to give narrative feedback regarding their acceptance of variation in care relate to the topic. A description of the collaborative along with its development, processes, and evolution are discussed. Process changes to address needs during the COVID-19 pandemic including expanded information sharing was necessary.

Results:

Collaborative membership reached across 5 states and included family medicine, internal medicine, and pediatrics. Members found involvement with the collaborative useful. Less variation in care was thought important for public health crises: the COVID pandemic and opioid epidemic. Greater practice variation was thought acceptable for adherence to multispecialty guidelines, such as diabetes, lipid management, and adult ADHD care. Process changes during the pandemic resulted in more communications between members to avoid practice gaps.

Conclusion:

An internet-based learning collaborative in a health system had good engagement from its members. Using novel methods, it was able to provide members with feedback related to the importance of new practice recommendations as perceived by their peers. Greater standardization was thought necessary when adopting measures to address public health crisis, and less necessary when addressing multispecialty guidelines. By employing a learning collaborative, this group was able to keep members interested and engaged. During the first year of the COVID pandemic the collaborative also served as a vehicle to share timely information.

Delivering end-of-life care for patients with cancer at home: Interviews exploring the views and experiences of general practitioners

Many patients with terminal cancer wish to die at home and general practitioners in the United Kingdom have a critical role in providing this care. However, it has been suggested general practitioners lack confidence in end-of-life care. It is important to explore with general practitioners their experience and perspectives including feelings of confidence delivering end-of-life care to people with cancer. The aim of this study was to explore general practitioners experiences of providing end-of-life care for people with cancer in the home setting and their perceptions of confidence in this role as well as understanding implications this has on policy design. A qualitative study design was employed using semi-structured interviews and analysed using thematic analysis. Nineteen general practitioners from London were purposively sampled from eight general practices and a primary care university department in 2018-2019, supplemented with snowballing methods. Five main themes were constructed: (a) the subjective nature of defining palliative and end-of-life care; (b) importance of communication and managing expectations; (c) complexity in prescribing; (d) challenging nature of delivering end-of-life care; (e) the unclear role of primary care in palliative care. General practitioners viewed end-of-life care as challenging; specific difficulties surrounded communication and prescribing. These challenges coupled with a poorly defined role created a spread in perceived confidence. Experience and exposure were seen as enabling confidence. Specialist palliative care service expansion had important implications on deskilling of essential competencies and reducing confidence levels in general practitioners. This feeds into a complex cycle of causation, leading to further delegation of care.

Shifting palliative care paradigm in primary care from better death to better end-of-life: a Swiss pilot study

BACKGROUND

Patients suffering from advanced cancer often loose contact with their primary care physician (PCP) during oncologic treatment and palliative care is introduced very late. The aim of this pilot study was to test the feasibility and procedures for a randomized trial of an intervention to teach PCPs a palliative care approach and communication skills to improve advanced cancer patients' quality of life.

METHODS

Observational pilot study in 5 steps. 1) Recruitment of PCPs. 2) Intervention: training on palliative care competencies and communication skills addressing end-of-life issues. 3) Recruitment of advanced cancer patients by PCPs. 4) Patients follow-up by PCPs, and assessment of their quality of life by a research assistant 5) Feedback from PCPs using a semi-structured focus group and three individual interviews with qualitative deductive theme analysis.

RESULTS

Eight PCPs were trained. Patient recruitment was a challenge for PCPs who feared to impose additional loads on their patients. PCPs became more conscious of their role and responsibility during oncologic treatments and felt empowered to take a more active role picking up patient's cues and addressing advance directives. They developed interprofessional collaborations for advance care planning. Overall, they discovered the role to help patients to make decisions for a better end-of-life.

CONCLUSIONS

While the intervention was acceptable to PCPs, recruitment was a challenge and a follow up trial was not deemed feasible using the current design but PCPs reported a change in paradigm about palliative care. They moved from a focus on helping patients to die better, to a new role helping patients to define the conditions for a better end-of-life.

TRIAL REGISTRATION

The ethics committee of the canton of Geneva approved the study (2018-00077 Pilot Study) in accordance with the Declaration of Helsinki.

Maßnahmen zur Verbesserung der allgemeinen ambulanten Palliativversorgung aus Sicht hausärztlicher Praxisteams

Hintergrund Zur Stärkung von AAPV fehlt es oftmals an Konkretisierung der Handlungsfelder für hausärztliche Praxisteams. Im Projekt „ALLPRAX“ wurde der Frage nachgegangen, welche Maßnahmen aus Sicht von Hausärzten und Medizinischen Fachangestellten das Potenzial haben, die AAPV in ihren jeweiligen Praxen zu verbessern.

Methode Acht Praxisteams wählten in jeweils einem Workshop anhand eines in einer vorherigen Projektphase entwickelten Maßnahmenkatalogs, geeignete Maßnahmen für eine Erprobung und Weiterentwicklung in ihrer eigenen Praxis aus.

Ergebnisse Die Praxisteams erachteten 35 aus 120 Maßnahmen für geeignet, die Palliativversorgung in ihrem Zuständigkeitsbereich zu verbessern. Am häufigsten wurden Maßnahmen zur vorausschauenden Versorgung von Patienten, Patienten- und Angehörigen-Beratung sowie Bildungsmaßnahmen für die Praxisteams ausgewählt.

Schlussfolgerung Zur Weiterentwicklung von AAPV in Hausarztpraxen bedarf es eines umfangreichen und zugleich differenzierten Interventionspakets.

Barriers and facilitators to e-learning in palliative care

BACKGROUND

E-learning provides opportunities for flexible learning to those who cannot access palliative education in the traditional classroom setting, but it also presents learners with challenges. The study aims to identify the barriers and facilitators to accessing e-learning courses in palliative care.

METHODS

Cross-sectional surveys were developed, piloted and disseminated to healthcare professionals (HCPs) working in palliative care on the island of Ireland (Republic of Ireland and Northern Ireland).

RESULTS

Important factors that motivated HCPs to participate in e-learning are: dedicated time; quick technical and administrative support; computer training before completing an e-learning course; and regular contact with the tutor in online course work. Some 50% indicated face-to-face assistance and hands-on training sessions as the type of support that they would like to receive.

CONCLUSIONS

Healthcare professionals' prior experiences and attitudes towards e-learning will guide educators developing programmes. This study indicates the prerequisite for organisational supports and practical considerations to facilitate the uptake of e-learning.

Changes in Pain Medication Profile among Patients Admitted to Specialized Home Palliative Care in Relation to Referral Source: An Exploratory Study

Pain is a common symptom leading to referrals to specialized home palliative care (SHPC) services and is known to affect patients' quality of life. To date, little is known about the impact of referral source on its management. To assess changes to pain medication profile in the course of SHPC and to identify potential differences in relation to referral source. This exploratory study is a retrospective analysis of 501 electronic medical records of a SHPC team in Germany. This included the assessment of baseline pain medication profiles according to the WHO analgesic ladder and changes to analgesic treatment in the course of SHPC with respect to referral source. At the time of admission, 77.4% of patients referred by a hospital and 78.8% of patients referred by the outpatient sector received a fixed analgesic regimen. In all, 61.9% of the inpatient group versus 62.9% of the outpatient group were treated with opioids, and 79.0% received modifications to pain medication at one point in time following admission. Thereby, patients referred by the outpatient sector received significantly earlier modifications and more supplementations of pain medication. Our study suggests positive development in the prescription of opioid analgesics compared to earlier studies in Germany. On the one hand, it highlights the relevance of thorough assessment and responsive evaluation of pain in SHPC, and on the other hand it reveals possible training needs of referring physicians, particularly those working in the outpatient sector. Our results inspired further research examining more closely the links between referral source and pain management.

Primary care service use by end-of-life cancer patients: a nationwide population-based cohort study in the United Kingdom

BACKGROUND

End of life (EoL) care becomes more complex and increasingly takes place in the community, but there is little data on the use of general practice (GP) services to guide care improvement. This study aims to determine the trends and factors associated with GP consultation, prescribing and referral to other care services amongst cancer patients in the last year of life.

METHODS

A retrospective cohort study of cancer patients who died in 2000-2014, based on routinely collected primary care data (the Clinical Practice Research DataLink, CPRD) covering a representative sample of the population in the United Kingdom. Outcome variables were number of GP consultations (primary), number of prescriptions and referral to other care services (yes vs no) in the last year of life. Explanatory variables included socio-demographics, clinical characteristics and the status of palliative care needs recognised or not. The association between outcome and explanatory variables were evaluated using multiple-adjusted risk ratio (aRR).

RESULTS

Of 68,523 terminal cancer patients, 70% were aged 70+, 75% had comorbidities and 45.5% had palliative care needs recognised. In the last year of life, a typical cancer patient had 43 GP consultations (Standard deviation (SD): 31.7; total = 3,031,734), 71.5 prescriptions (SD: 68.0; total = 5,074,178), and 21(SD: 13.0) different drugs; 58.0% of patients had at least one referral covering all main clinical specialities. More comorbid conditions, prostate cancer and having palliative care needs recognised were associated with more primary care consultations, more prescriptions and a higher chance of referral (aRRs 1.07-2.03). Increasing age was related to fewer consultations (aRRs 0.77-0.96), less prescriptions (aRR 1.09-1.44), and a higher chance of referral (aRRs 1.08-1.16) but less likely to have palliative care needs recognised (aRRs 0.53-0.89).

CONCLUSIONS

GPs are very involved in end of life care of cancer patients, most of whom having complex care needs, i.e. older age, comorbidity and polypharmacy. This highlights the importance of enhancing primary palliative care skills among GPs and the imperative of greater integration of primary care with other healthcare professionals including oncologists, palliative care specialists, geriatricians and pharmacists. Research into the potential of deprescribing is warranted. Older patients have poorer access to both primary care and palliative care need to be addressed in future practices.

How to ensure basic competencies in end of life care - a mixed methods study with post-graduate trainees in primary care in Germany

Background

Providing end of life care (EoLC) is an important aspect of primary care, which reduces the risk of hospital admission for most patients. However, general practitioners (GPs) seem to have low confidence in their ability to provide EoLC. Little is known about an adequate volume and kind of training in EoLC among GP trainees.

Methods

We performed a before-after comparison in all post-graduate GP trainees who were registered in the vocational training program (KWBW VerbundweiterbildungPLUS). They were offered participation within a two-day seminar focussing on palliative care in 2017. Those who attended the seminar (intervention group I) completed a paper-based questionnaire directly before the intervention (T₁) and 6 months after (T₂). None-attendees (group C) were also asked to fill out the questionnaire once. The questionnaire covered previous experiences in palliative care, self-assessment of competencies in EoLC in the organisation of patient care as well as in control of symptoms, attitudes towards death and caring for dying patients and questions about GPs’ role in EoLC.

Results

In total, 294 GP trainees (I: n = 219; C: n = 75) participated in the study. Of those, more than 90% had previously gained experience in EoLC mainly during vocational training in the hospital rotation. Around a third had previously gained competencies in EoLC in medical school. Between groups I (T₁) and C no significant differences were observed in socio-demographic characteristics, pre-existing experience or overall expertise. At T_2, 75% of participants of group I declared they have extended their competencies in EoLC after the intervention and 70% classified the intervention as helpful or very helpful. Overall, they rated their competencies significantly higher than at T₁ (p < 0.01). In detail, competencies in organisation of EoLC and competencies in handling of symptoms significantly improved (p < 0.01). Due to the intervention, 66% could reflect their attitudes towards dying, death and grief and 18% changed their attitudes. Group I highlighted palliative care as one of GPs tasks (Likert 4.47/5, SD 0.75).

Conclusions

The intervention fostered personal competencies, understanding and self-confidence in EoLC among GP trainees. This is crucial for the aim to broadly provide EoLC.

Perspectives Of Health Professionals And Educators On The Outcomes Of A National Education Project In Pediatric Palliative Care: The Quality Of Care Collaborative Australia

PURPOSE

Demand for generalist health professional knowledge and skills in pediatric palliative care (PPC) is growing in response to heightened recognition of the benefits of a palliative approach across the neonatal, pediatric, adolescent and young adult lifespan. This study investigates factors that enhanced PPC workforce capability and education outcomes in metropolitan and regional areas through the integration of dedicated educator roles within specialist pediatric palliative care (SPPC) teams through a national education project.

METHODS

Cross-sectional, prospective qualitative study guided by the Consolidated Criteria for Reporting Qualitative Studies. The study drew on Discovery Interview methodology and transcripts subjected to inductive thematic analysis. A convenience sample (n=16) of health professionals and educators were recruited from specialist tertiary and regional services providing PPC in Australia.

RESULTS

Four themes emerged related to outcomes of the national PPC education project: (1) building capability in PPC, (2) developing inter-professional partnerships, (3) sustaining staff well-being, and (4) learning from children and families. Dedicated educator roles in SPPC services enhanced workforce capability through education and ongoing mentoring, built collaborative relationships between the complex network of care providers for children with a life-limiting condition (LLC) and their families, and improved quality and access to PPC. Delivery of education evolved from didactic to interactive engagement and coincided with development of a mentoring model between SPPC clinicians and generalist health and social care providers.

CONCLUSION

This study contributes to a growing body of knowledge on innovative and responsive mechanisms for enhancing workforce capability in PPC and provides additional evidence to support funding of dedicated educator roles in specialist PPC services.

Knowledge and attitudes toward end-of-life care among community health care providers and its influencing factors in China: A cross-sectional study

A majority of nurses struggled with a negative emotion of anger, doubt, fear, or anxious, uncomfortable in the face of death and dying. However, little was known about community health care providers' in China. Therefore, we conducted a study to investigate their knowledge and attitudes toward end-of-life care and analyze its influencing factors. To provide reference for developing effective strategies to promote end-of-life care in China.A total of 132 community health care providers of 10 community health care centers in Changzhi city were investigated by a Questionnaire of Knowledge and Attitudes toward Caring for the Dying from May, 2017 to December, 2017, and data was analyzed by SPSS 22.0 software.Of the 132 community health care providers who were under investigation, 70 knew about hospice care, but they rated their overall content on end-of-life care as inadequacy, especially in communication skills and knowledge of pain management. The average score of attitudes was 3.47 (SD = 0.44), the lowest score was in the subscale of nurse-patient communication, which was 2.91 (SD = 0.65). Health care providers who had worked for more than 11 years, who had experiences of the death of relatives or friends, and who had previous experiences of caring for terminal patients had more positive attitudes toward caring for the dying (P < .05 for all). There was a significant relationship between community health care providers' attitudes toward death and their attitudes toward end-of-life care (r = -0.282, P < .01). The significant predictors of attitudes toward end-of-life care were attitudes toward death (β = -0.342), experiences of the death of relatives (β=-0.207), experiences of caring for the dying (β = 0.185), and working experience (β = 0.171).Community health care providers had positive attitudes toward end-of-life care, but they lacked systematic and professional knowledge and skills of caring for the terminal patients. Education is the top priority. It is imperative to set up palliative care courses and life-death education courses, establish an indigenous end-of-life care model, and improve policies, systems, and laws to promote end-of-life care.

Clinician barriers and facilitators to heart failure advance care plans: a systematic literature review and qualitative evidence synthesis

BACKGROUND

Clinicians hesitate to engage with advance care planning (ACP) in heart failure. We aimed to identify the disease-specific barriers and facilitators for clinicians to engage with ACP.

METHODS

We searched Medline, Embase, CINAHL, PubMed, Scopus, the British Nursing Index, the Cochrane Library, the EPOC register, ERIC, PsycINFO, the Science Citation Index and the Grey Literature from inception to July 2018. We conducted the review according to Enhancing Transparency in Reporting the Synthesis of Qualitative Research (ENTREQ) guidelines. Two reviewers independently assessed original and empirical studies according to Critical Appraisal Skills Programme criteria. The SURE framework and thematic analysis were used to identify barriers and facilitators.

RESULTS

Of 2308 articles screened, we reviewed the full text of 42 studies. Seventeen studies were included. The main barriers were lack of disease-specific knowledge about palliative care in heart failure, high emotional impact on clinicians when undertaking ACP and lack of multidisciplinary collaboration between healthcare professionals to reach consensus on when ACP is indicated. The main facilitators were being competent to provide holistic care when using ACP in heart failure, a patient taking the initiative of having an ACP conversation, and having the resources to deliver ACP at a time and place appropriate for the patient.

CONCLUSIONS

Training healthcare professionals in the delivery of ACP in heart failure might be as important as enabling patients to start an ACP conversation. This twofold approach may mitigate against the high emotional impact of ACP. Complex interventions are needed to support clinicians as well as patients to engage with ACP.

Pediatric palliative care in the medical neighborhood for children with medical complexity

Children with medical complexity (CMC) are a medically fragile pediatric population that experience severe chronic illnesses resulting in significant health care needs, functional limitations, and health care utilization, and are at the highest risk for morbidity and mortality among all children. Furthermore, families and parents of CMC experience significant caregiver hardships and diminished quality of life. The field of pediatric palliative care has grown in recent years, in part to address the physical and psychosocial issues inherent to the care of these chronically ill children. However, as the prevalence and long-term survival of CMC increases with medical advancements, the demand for pediatric palliative care will likely exceed the capacity of current and future pediatric palliative care specialists. Therefore, alternative strategies to ensure access to essential aspects of palliative care must be considered. This article focuses on why and how high-quality palliative care should be integrated into the patient- and family-centered medical home, the ideal care delivery model for CMC and their families. We first discuss how palliative care principles naturally align with and complement the goals of the CMC medical home. Next, we detail what actions pediatric palliative care specialists can take to best support the CMC medical home as "medical neighbors." Lastly, we describe the fundamental aspects of pediatric palliative care that all clinicians caring for CMC should be able to provide, referred to as "primary pediatric palliative care." (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Perspectives of bereaved relatives of patients with haematological malignancies concerning preferred place of care and death: A qualitative study

BACKGROUND

People with haematological malignancies have different end-of-life care patterns from those with other cancers and are more likely to die in hospital. Little is known about patient and relative preferences at this time and whether these are achieved.

AIM

To explore the experiences and reflections of bereaved relatives of patients with leukaemia, lymphoma or myeloma, and examine (1) preferred place of care and death; (2) perceptions of factors influencing attainment of preferences; and (3) changes that could promote achievement of preferences.

DESIGN

Qualitative interview study incorporating 'Framework' analysis.

SETTING/PARTICIPANTS

A total of 10 in-depth interviews with bereaved relatives.

RESULTS

Although most people expressed a preference for home death, not all attained this. The influencing factors include disease characteristics (potential for sudden deterioration and death), the occurrence and timing of discussions (treatment cessation, prognosis, place of care/death), family networks (willingness/ability of relatives to provide care, knowledge about services, confidence to advocate) and resource availability (clinical care, hospice beds/policies). Preferences were described as changing over time and some family members retrospectively came to consider hospital as the 'right' place for the patient to have died. Others shared strong preferences with patients for home death and acted to ensure this was achieved. No patients died in a hospice, and relatives identified barriers to death in this setting.

CONCLUSION

Preferences were not always achieved due to a series of complex, interrelated factors, some amenable to change and others less so. Death in hospital may be preferred and appropriate, or considered the best option in hindsight.

Experiences and perceptions of online continuing professional development among clinicians in sub-Saharan Africa

BACKGROUND

Limitations in healthcare worker (HCW) capacity compound the burden of dual TB and HIV epidemics in sub-Saharan Africa. To fill gaps in knowledge and skills, effective continuing profession development (CPD) initiatives are needed to support practicing HCWs reach high standards of care. e-learning opportunities can bring expert knowledge to HCWs in the field and provide a flexible learning option adaptable to local settings. Few studies provide insight into HCW experiences with online CPD in the developing country context.

METHODS

An online survey using both close-ended and free response was conducted to HCWs in sub-Saharan Africa who completed the University of Washington (UW) School of Medicine online graduate course, "Clinical Management of HIV." Associations between respondent characteristics (age, gender, rural/urban, job title) and learning preferences, course barriers, and facilitators with an emphasis on online courses were examined using chi-square. Covariates significant at the p < 0.05 were analyzed using multivariable logistic regression. Responses to open-ended comments were analyzed using simplified grounded theory.

RESULTS

Of 2,299 former students, 464 (20%) HCWs completed surveys from 13 countries: about half were women. Physicians (33%), nurses (27%), and clinical officers (30%) responded mostly from urban areas (67%) and public institutions (69%). Sixty-two percent accessed the online course from work, noting that slow (55%) or limited (41%) internet as well as lack of time (53%) were barriers to course completion. Women (p < 0.001) and HCWs under age 40 (p = 0.007) were more likely to prefer learning through mentorship than men or older HCWs. Respondents favored group discussion (46%), case studies (42%), and self-paced Internet/computer-based learning (39%) and clinical mentorship (37%) when asked to choose 3 preferred learning modalities. Free-response comments offered additional positive insights into the appeal of online courses by noting the knowledge gains, the flexibility of format, a desire for recognition of course completion, and a request for additional online coursework.

CONCLUSIONS

Online CPD opportunities were accepted across a diverse group of HCWs from sub-Saharan Africa and should be expanded to provide more flexible opportunities for self-initiated learning; however, these need to be responsive to the limited resources of those who seek these courses.

A Systematic Review of End-of-Life Care Communication Skills Training for Generalist Palliative Care Providers: Research Quality and Reporting Guidance

CONTEXT

End-of-life care (EoLC) communication skills training for generalist palliative care providers is recommended in policy guidance globally. Although many training programs now exist, there has been no comprehensive evidence synthesis to inform future training delivery and evaluation.

OBJECTIVES

To identify and appraise how EoLC communication skills training interventions for generalist palliative care providers are developed, delivered, evaluated, and reported.

METHODS

Systematic review. Ten electronic databases (inception to December 2015) and five relevant journals (January 2004 to December 2015) were searched. Studies testing the effectiveness of EoLC communication skills training for generalists were included. Two independent authors assessed study quality. Descriptive statistics and narrative synthesis are used to summarize the findings.

RESULTS

From 11,441 unique records, 170 reports were identified (157 published, 13 unpublished), representing 160 evaluation studies of 153 training interventions. Of published papers, eight were of low quality, 108 medium, and 41 high. Few interventions were developed with service user involvement (n = 7), and most were taught using a mixture of didactics (n = 123), reflection and discussion (n = 105), and role play (n = 86). Evaluation designs were weak: <30% were controlled, <15% randomized participants. Over half (n = 85) relied on staff self-reported outcomes to assess effectiveness, and 49% did not cite psychometrically validated measures. Key information (e.g., training duration, participant flow) was poorly reported.

CONCLUSIONS

Despite a proliferation of EoLC communication skills training interventions in the literature, evidence is limited by poor reporting and weak methodology. Based on our findings, we present a CONSORT statement supplement to improve future reporting and encourage more rigorous testing.