Opinion & Special Article: Next Steps in Palliative Care Education for Neurology Residents

Pediatric Palliative Care Education in Child Neurology Residency: A National Needs Assessment

BACKGROUND

Child neurologists require primary palliative care (PC) skills to care for patients with high symptom burdens and variable prognoses. The existing scope of PC education in child neurology training is unclear. We conducted a national survey-based needs assessment of pediatric PC education in child neurology residencies in the United States.

METHODS

Resident and program surveys were developed and distributed via direct recruitment of program directors/coordinators and the Child Neurology Society Connect platform. Surveys were analyzed using descriptive statistics and exploratory posthoc comparisons in specific comparison groups.

RESULTS

Seventy-nine residents and 18 programs completed the survey. Respondents represented all US census regions and neurology training years. Curricular and clinical exposure to six core pediatric PC topics varied: 17 (22%) residents participated in a PC rotation, three programs (17%) require a PC rotation, and 13 programs (72%) offer a PC elective. Increasing postgraduate year (PGY) level and PC elective experience were associated with increased confidence in elements of serious illness communication, and increasing PGY level was also associated with increased confidence in elements of neuroprognostication and palliative symptom management. Both residents and programs reported a desire and motivation for additional pediatric PC education.

CONCLUSIONS

Current child neurology residents reported increased confidence over PGY level across three of six pediatric PC domains. Still, respondents reported desire and motivation for additional training. Our results highlight that although some primary PC skills are developed in child neurology residencies, there is a need for more formalized and enhanced pediatric PC education.

End-of-Life and Hospice Care in Neurologic Diseases

The care of a patient with neurologic disease at end-of-life requires expertise in addressing advance care planning, hospice, symptom management, and caregiver support. Neurologists caring for patients with advanced neurologic disease often identify changes in disease trajectory, functional status, or goals of care that prompt discussions of advance care planning and hospice. Patients nearing end-of-life may develop symptoms such as dyspnea, secretions, delirium, pain, and seizures. Neurologists may be the primary clinicians managing these symptoms, particularly in the hospitalized patient, though they may also lend their expertise to non-neurologists about expected disease trajectories and symptoms in advanced neurologic disease. This article aims to help neurologists guide patients and caregivers through the end-of-life process by focusing on general knowledge that can be applied across diseases as well as specific considerations in severe stroke and traumatic brain injury, amyotrophic lateral sclerosis, Parkinson's disease, and dementia.

Neurologists' Attitudes and Perceptions on Palliative Care: A Qualitative Study

Background and Objectives

Despite significant advances in the treatment of neurologic disorders, many conditions require complex care planning and advanced care planning. Neurologists are in a unique position because they are integral in providing patient centered care, understanding neurologic disease and illness trajectory, and how disease can affect patients' sense of self and values. Currently, little is known about neurologists' perceptions and challenges in care planning and palliative care for their patients.

Methods

Neurologists from one Canadian academic institution participated in a 30-minute semistructured interview from November 2022 to April 2023. Interviews were conducted until saturation was reached and confirmed. Interviews occurred online through a secure platform or in-person and were recorded. Data were analyzed using a constant comparative method using constructivist grounded theory. Member checking was conducted post interview.

Results

Ten neurologists participated across a broad spectrum of neurology experience and subspecialties. We developed a detailed theory of understanding neurologists' attitudes and perceptions of palliative care. When neurologists delay or fail to initiate care planning discussions or palliative care, it results from a complex interplay between patient, physician, and resource accessibility factors. Certain contextual factors, such as a first visit or follow-up, inpatient vs outpatient setting, clinic culture, and the type of clinic practice, are factors that can influence these conversations. As a result, physicians may fail to use available resources, or they may involve other care providers or refer to subspecialty neurologic clinics. However, this delay can still lead to patient and provider harm. Opportunities to improve care exist with continuing education opportunities for trainees and staff, collaboration with palliative care specialists, and health systems support, such as increasing public awareness to address misconceptions about palliative care and resource availability.

Discussion

Our findings identify that failure or delay to initiate care planning and palliative care by neurologists results from a complex interplay between local culture, experience, context, practice type, and patient factors. Opportunities to improve care include increasing educational opportunities, building integrated and collaborative practices, and dedicated health systems support.

Communication in Neuropalliative Care

Serious illness communication needs are high among patients with neurological conditions, from the time of diagnosis to the end of life. This article will highlight unique needs among these patients, strategies for optimizing communication, and techniques to learn and teach these skills along the continuum of a career in neurology.

Education needs in palliative care and advance care planning of Italian residents in neurology: an online survey

BACKGROUND AND PURPOSE

Most neurological diseases have a chronic and progressive clinical course, with patients living for extended periods with complex healthcare needs. Evidence from other countries suggests that palliative care (PC) is insufficiently integrated in the care of these patients. This study aims to identify PC and advance care planning (ACP) knowledge and the perceived preparedness of Italian residents in neurology.

METHODS

This is a cross-sectional online survey of physicians attending the 36 Italian neurology residency programmes.

RESULTS

Of 854 residents, 188 (22%) participated. Their mean age was 28.4 ± 2.0 years; 49% were women; 45% were from the north, 23% from the centre and 32% from the south of Italy. Few residents (6%) reported that a teaching course in PC was part of the graduate programme, and 3% of the postgraduate programme. During their residency, 9% of participants received PC training, and 18% ACP training. Only 13% reported to have participated in the ACP process, half within their neurology residency programme. Residents considered PC support very/extremely important in all the pre-specified clinical situations, with values ranging between 78% and 96%. Over 70% of residents revealed education needs, particularly concerning ACP.

CONCLUSIONS

Our data confirm the need for improving PC training in the graduate and postgraduate curriculum. This, together with collaboration and joint training of neurology and PC, is essential to improve the quality and continuity of care and respond to the complex needs of people with neurological disorders causing severe disability.

The impact of palliative care on the frailty-stroke continuum: from theoretical concepts to practical aspects

With a constant increase in prevalence and incidence worldwide, stroke remains a public health issue in the 21st century. Additionally, population aging inevitably leads to increased vulnerability in the general population, a clinical state known as frailty. While there are adequate guidelines on the treatment of stroke in the acute setting, there are a lot of gaps regarding the chronic management of stroke patients, particularly the frail ones. From the therapeutic point of view, palliative care could be the key to offering complex and individualized treatment to these frail chronic stroke patients. In the context of the heterogeneous data and incomplete therapeutic guidelines, this article provides a new and original perspective on the topic, aiming to increase awareness and understanding and improve palliative care management in stroke patients. Based on current knowledge, the authors describe a new concept called the frailty-stroke continuum and offer a detailed explanation of the intricate stroke-frailty connection in the first part. After understanding the role of palliative care in managing this kind of patients, the authors discuss the most relevant practical aspects aiming to offer an individualized framework for daily clinical practice. The novel approach consists of developing a four-step scale for characterizing frail stroke patients, with the final aim of providing personalized treatment and correctly evaluating prognosis. By pointing out the limitations of current guidelines and the challenges of new research directions, this article opens the pathway for the better evaluation of frail stroke patients, offering a better perception of patients' prognosis.

Curriculum Research: Disseminating Neuropalliative Care Education Through an Adaptable Curriculum: A Multisite Feasibility Trial

Introduction and Problem Statement

Neurologic disease is a leading cause of disability and death worldwide. As the global population ages, the burden of these diseases is expected to increase. Despite this increased clinical need, neurology trainees are seldom taught skills and concepts in palliative care. Education in Palliative and End-of-Life Care for Neurology (EPEC-N) is a publicly available neuropalliative care curriculum designed to be taught by both palliative care specialists and nonspecialists alike.

Objectives

(1) To create a feasible curriculum in neuropalliative care using EPEC-N, (2) to improve learners' satisfaction with neuropalliative care training, and (3) to improve learners' confidence with neuropalliative care topics.

Methods and Curriculum Description

Three academic centers implemented a neuropalliative care curriculum for neurology residents using EPEC-N modules. Each site selected 4 of the 26 topics. Instructor backgrounds varied by site and included neurology senior residents, fellows, and faculty; none had completed palliative care fellowship at the time of teaching. Teaching methods included lecture, case discussion, and role-play. To assess feasibility and acceptability of this curriculum, learners, instructors, and site leads completed postsession surveys.

Results and Assessment Data

A total of 87 residents attended at least 1 didactic session, and 23 residents completed the evaluation survey. All 3 sites were able to successfully implement an evidence-based and subspecialist-approved neuropalliative care curriculum without relying on subspecialty instruction, despite variations in instructor background, curriculum format, and module selection. Learners overall expressed a positive experience with this curriculum, with most of the respondents indicating that each session was effective in improving their knowledge base, relevant to current practice, and provided in an effective teaching format. Site leads and instructors found the curriculum easy to use, in minimal need of modification, and helpful for delivering neuropalliative care education.

Discussion and Lessons Learned

The EPEC-N curriculum was successfully implemented at 3 US sites, demonstrating feasibility, acceptability, and adaptability across institutions. Further research is needed to evaluate the effectiveness of this curriculum in improving neuropalliative care skills for neurologists and raising the standard of primary neuropalliative care.

Palliative Care Psychiatry: Building Synergy Across the Spectrum

PURPOSE OF REVIEW

Palliative care (PC) psychiatry is a growing subspecialty focusing on improving the mental health of those with serious medical conditions and their caregivers. This review elucidates the current practice and ongoing evolution of PC psychiatry.

RECENT FINDINGS

PC psychiatry leverages training and clinical practices from both PC and psychiatry, addressing a wide range of needs, including enhanced psychiatric care for patients with serious medical illness, PC access for patients with medical needs in psychiatric settings, and PC-informed psychiatric approaches for individuals with treatment-refractory serious mental illness. PC psychiatry is practiced by a diverse workforce comprising hospice and palliative medicine-trained psychiatrists, psycho-oncologists, geriatric psychiatrists, other mental health professionals, and non-psychiatrist PC clinicians. As a result, PC psychiatry faces challenges in defining its operational scope. The manuscript outlines the growth, current state, and prospects of PC psychiatry. It examines its roles across various healthcare settings, including medical, integrated care, and psychiatric environments, highlighting the unique challenges and opportunities in each. PC psychiatry is a vibrant and growing subspecialty of psychiatry that must be operationalized to continue its developmental trajectory. There is a need for a distinct professional identity for PC psychiatry, strategies to navigate administrative and regulatory hurdles, and greater support for novel clinical, educational, and research initiatives.

Palliative Care in Neuro-oncology: an Update

PURPOSE OF REVIEW

While the benefits of palliative care for patients with cancer are well established, palliative care in neuro-oncology is still in its early stages. However, in recent years, there has been increasing attention drawn to the need for better palliative care for patients with brain tumors.

RECENT FINDINGS

There is a growing body of literature demonstrating the high symptom burden and significant supportive care and information needs of these patients and their caregivers. In the area of caregiver needs, the last 3 years has seen a more rapid growth in recognizing and characterizing these needs. However, there remains a knowledge gap regarding the optimal means of addressing these needs. In this article, we outline important recent advances in the literature on palliative care for patients with brain tumors and highlight areas in need of greater attention and investigation.

Emerging Subspecialties in Neurology: Cortical Careers in Neuropalliative Care

Serious neurologic illnesses are associated with significant palliative care (PC) needs, including symptom management, complex decision-making, support for caregivers, and end-of-life care. While all neurologists are responsible for the provision of primary PC, there is an increasing need for trained neurologists with expertise in palliative medicine to manage refractory symptoms, mitigate conflict around goals of care, and provide specialized end-of-life care. This has led to the emergence of neuropalliative care (NPC) as a subspecialty. There are different ways to acquire PC skills, incorporate them into one's neurology practice, and develop a neuropalliative carer. We interviewed 3 leaders in the field of NPC, Dr. Robert Holloway, Dr. Jessica McFarlin, and Dr. Janis Miyasaki, who are all neurologists with different subspecialties and training pathways working in academic centers. They share their career paths, their advice for neurology trainees interested in pursuing a career in NPC, and their thoughts on the future of the field.

Education in neuropalliative care

The importance and value of providing palliative care for patients with neurologic disease is increasingly recognized. While palliative and neuropalliative specialists may be well-positioned to provide this care, there is a shortage of specialists to address these needs. As a result, much of the upfront palliative care will naturally be provided by the treating neurologist. It is imperative that all neurologists receive quality training in primary palliative care skills. As the subspecialty of neuropalliative care grows, the need for specialty neuropalliative education has arisen. This chapter reviews existing educational initiatives and common neuropalliative-oriented career tracks and identifies opportunities for growth along the continuum of medical education and beyond.

A Narrative Review of Problems in Learning and Practicing Palliative Care in Neurology Clinics in Japan and Proposed Solutions

As the understanding of the role of palliative care in neurology increases, there is the need to ensure that these developments include not only care at home and in hospitals but also in clinics. There are no reports on palliative care from neurology clinics in Japan, and this paper considers the problems and proposed solutions for improving palliative care provided at neurology clinics in Japan. In Japan, physicians in neurology clinics are extremely busy both during and after office hours with medical treatment and the preparation of various documents and are unable to conduct case conferences. Moreover, the education system for palliative care, especially for lifelong education, is not sufficient, and multidisciplinary cooperation is difficult due to the lack of specialists and their scattered locations. To improve the care provided for patients and their families, general palliative care should be included in the health insurance system with incentives and recognition, and mandatory lifelong education should be established so that all neurologists can provide palliative care. These proposals may be appropriate for other countries as palliative care in neurology is established.

Prognostication in neurology

Prognosticating is central to primary palliative care in neurology. Many neurologic diseases carry a high burden of troubling symptoms, and many individuals consider health states due to neurologic disease worse than death. Many patients and families report high levels of need for information at all disease stages, including information about prognosis. There are many barriers to communicating prognosis including prognostic uncertainty, lack of training and experience, fear of destroying hope, and not enough time. Developing the right mindset, tools, and skills can improve one's ability to formulate and communicate prognosis. Prognosticating is subject to many biases which can dramatically affect the quality of patient care; it is important for providers to recognize and reduce them. Patients and surrogates often do not hear what they are told, and even when they hear correctly, they form their own opinions. With practice and self-reflection, one can improve their prognostic skills, help patients and families create honest roadmaps of the future, and deliver high-quality person-centered care.