Position paper on undergraduate Palliative Medicine education for doctors in South Africa

South African palliative care provider perspectives on emergency medical services in palliative situations

Introduction

Due to the frequent intersection of Emergency Medical Services (EMS) with palliative situations and the increasing global need for palliative care, there has been increased recognition of the need for palliative care integration with EMS. However, EMS and palliative care systems remain segregated in many Low-to-Middle Income Country contexts, as in South Africa (SA). The aim of this study was to gather perspectives of palliative care providers in SA concerning EMS in palliative situations.

Methods

A qualitative design employing individual semi-structured interviews was implemented. Ten interviews with experienced doctors and nurses holding post-graduate palliative medicine qualifications were conducted. Verbatim transcriptions of interviews were subjected to content analysis with an inductive-dominant approach to develop codes and categories.

Results

Four categories were developed: (1) Disposition towards EMS, (2) Perceived EMS challenges, (3) Positive EMS impact across patients' palliative care journeys and (4) Methods of EMS and palliative care system integration. Participants maintained an overall positive view of EMS and palliative care integration, noting the beneficial impact of EMS and suggesting various methods of integration, while also highlighting challenges and concerns.

Conclusion

EMS and palliative care integration would be mutually beneficial to both systems while benefiting patient well-being and the broader healthcare system. Potentially low-cost, high-impact interventions suggested by participants, such as palliative care cards for patients and enhancing EMS and palliative care system communication, represent efficacious and judicious use of limited resources within the SA context. Pilot studies investigating these suggestions should be conducted.

Healthcare workers' knowledge of indicators for a palliative care approach

BACKGROUND

 Palliative care is an essential element of universal healthcare, yet not all people who need palliative care are able to receive it. One of the barriers to ensuring access for people who require palliative care is the identification of those eligible.

AIM

 This study evaluated healthcare workers' ability to identify patients who are eligible for palliative care based on their training or experience in palliative care.

SETTING

 The setting for the study comprised the Heideveld Emergency Centre and Heideveld Community Day Centre in the Cape Metro, Cape Town, South Africa.

METHODS

 This study made use of a cross-sectional survey of healthcare workers.

RESULTS

 Of the 55 participants in this study, most were able to correctly identify patients with cancer and chronic kidney disease as needing palliative care, but less accurate with other organ failure categories, trauma indications, or functional assessment of the patient. Participants who reported previous awareness training reported improved knowledge on the indications for a palliative care approach compared to no prior training.

CONCLUSION

 Our cohort was too small to analyse the results statistically. From what was analysed, the ability of healthcare workers to identify a person in need of palliative care could be better; more work is needed on our awareness training and basic training courses to improve this vital step.Contribution: This research highlights the fact that existing training for palliative care needs to be more applicable to the setting and that training of staff with existing courses does make a difference in knowledge.

The influence of context on the implementation of integrated palliative care in an academic teaching hospital in South Africa

Background

Palliative care (PC) has been integrated to a limited extent in the South African healthcare system. Contextual factors may be a pivotal influence in this integration.

Objectives

This study aims to explore contextual factors that are possibly influencing the integration or lack thereof in an academic teaching hospital (ATH).

Design

A mixed-method study was conducted in a large ATH in South Africa.

Methods

The mixed methods were conducted in parallel and then merged. Findings were integrated to describe the contextual factors influencing PC integration, to develop a timeline of implementation and assess the probable influence of context on the integration process. The mixed-methods phases included a narrative review of published literature related to health systems, integration of health interventions and PC in teaching hospital settings; followed by interviews, documentary and routine data analyses. Semi-structured interviews with purposively sampled participants provided the qualitative data. Primary national, provincial and organizational documents expanded the contextual phenomena and corroborated findings. Routine hospital admission and mortality data was statistically analysed to expand further and corroborate findings. All qualitative data was thematically analysed using deductive coding, drawing from the aspects of the contextual dimensions of integration.

Results

Enabling contextual factors for local PC integration were global and local advocacy, demonstrated need, PC being a human right, as well as the personal experiences of hospital staff. Impeding factors were numerous misconceptions, PC not valued as a healthcare priority, as well as limitations in functional elements necessary for PC integration: national and regional political support, leadership at all levels and sustainable financing.

Conclusion

The normative and functional contextual aspects interplay at macro, meso and micro levels positively and negatively. How stakeholders understand and value PC directly and indirectly impacts on PC integration. Strategic interventions such as mandatory education are required to ensure PC integration. The health system is dynamic, and understanding the context in which the health system functions is core to the integration of PC. This may assist in developing integration strategies to address PC integration and the transferability of these strategies.

What do medical students and their clinical preceptors understand by primary health care in South Africa? A qualitative study

BACKGROUND

The definition of Primary Health Care (PHC) issued by the World Health Organisation in 1978 indicated that essential health care should be made accessible to individuals and their communities close to where they live and work. In 1992 Starfield articulated the four pillars of PHC: the patient's first contact with healthcare, comprehensive care, coordinated care and continuous care. Using this literature guidance, this study sought to explore what undergraduate medical students and their clinical preceptors understood by PHC in four South African medical schools.

METHODS

A qualitative study using the phenomenological design was conducted among undergraduate medical students and their clinical preceptors. The setting was four medical schools in South Africa (Sefako Makgatho Health Sciences University, Walter Sisulu University and the University of KwaZulu-Natal and the Witwatersrand University). A total of 27 in-depth interviews were conducted among the clinical preceptors and 16 focus group discussions among the students who were in their clinical years of training (MBChB 4-6). Interviews were digitally recorded and transcribed verbatim, followed by thematic data analysis using the MAXQDA 2020 (Analytics Pro) software.

RESULTS

Four themes were identified in which there were similarities between the students and their preceptors regarding their understanding of PHC: (1) PHC as the patient's first contact with the healthcare system; (2) comprehensive care; (3) coordination of care and (4) continuity of care. A further two themes were identified in which these two groups were not of similar understanding: (5) PHC as a level or an approach to healthcare and (6) the role of specialist clinical preceptors in PHC.

CONCLUSIONS

Medical students and their clinical preceptors displayed an understanding of PHC in line with four pillars articulated by Starfield and the WHO definition of PHC. However, there remains areas of divergence, on which the medical schools should follow the guidance provided by the WHO and Starfield for a holistic understanding of PHC.

Advance Care Planning in South Africa

South Africa (SA), an upper middle-income country, faces significant challenges, including severe inequality, poverty, high unemployment rates, unequal access to basic services, and a long history of human rights violations. It is a diverse nation with eleven official languages. The country also bears a heavy burden of communicable and non-communicable diseases, with many patients seeking healthcare services too late. Despite the pressing need, palliative care is still an emerging field in South Africa, with limited funding allocated for its integration. Advance Care Planning (ACP) is a recommended practice in SA for patients with serious illnesses while they are still in good health and can function independently. Non-Governmental Organizations (NGOs) in SA have played a significant role in integrating ACP planning within their settings through advocacy and training. ACP has been included in both formal academic training and training programs offered by NGOs. Additionally, research has been initiated to evaluate the acceptability and validity of the Serious Illness Conversation Guide within the cultural diversity and complexities of the SA context. Acceptance of ACP amongst SA healthcare workers and the public faces many challenges. Many South Africans still have a low level of trust and acceptance towards the public healthcare system. In many South African cultures discussing death and dying is considered culturally taboo. Traditional cultures interpret and apply the concept of individual autonomy differently. The philosophy of "Ubuntu", which translates to "I am because we are", is widely endorsed in the country, prioritising community needs over individual needs. It is, therefore, essential for healthcare professionals engaging in ACP conversations not to make assumptions about a person's preferences for communication, decision-making and care, based on external attributes. Instead, they should respectfully explore these preferences and be adaptable in their approach to ACP. The implementation of ACP in SA is still in its early stages, requiring further research to inform culturally sensitive approaches to advance care planning.