Palliative Education Research Articles

Development of the Standard Hospice and Palliative Care Education Program in Korea: Results from the Demonstration Project

To describe development of the Standard Hospice & Palliative Care Education Program in Korea, a basic training program for hospice & palliative care professionals, and to report preliminary results from the 2008-2009 demonstration project at 2 sites that support its effectiveness. We developed the Standard Hospice & Palliative Care Education Program, consisting of 19 modules, under the initiative and financial support of the Ministry of Health, Welfare, and Family Affairs. We adapted the train-the-trainer model and benchmarked the EPEC (Education in Palliative and End-of-life Care) course. In order to evaluate the effectiveness of the program, session evaluation, pre-post test of knowledge, and overall course evaluation were assessed by participants. The demonstration program included a total of 105 participants. Overall rating by participants was 4.1 for relevance and usefulness of program contents (range, 4.1-4.2; 1 = strongly disagree, 5 = strongly agree) and 4.1 for the trainer's teaching skills (range, 4.0-4.2). Participants demonstrated significant improvement in their knowledge on the pre-post test for 6 of the 17 modules, and reported that they had gained confidence in their ability to perform palliative care practices (overall mean ratings, 4.0, range; 3.6-4.3; 1 = very low, 5 = very high). Overall evaluation of the program was very high (very satisfied or satisfied; 86%). Development of the Standard Hospice & Palliative Care Education Program was successful, and its preliminary effectiveness was shown by the demonstration program. Comments on our experience in Korea would be helpful to efforts in other countries, particularly those with limited resources for hospice and palliative care.

Expanding the Reach of a Cancer Palliative Care Curriculum Through Web-Based Dissemination: A Public–Private Collaboration

Deficiencies in palliative and end-of-life care have been well documented by the Institute of Medicine. The National Cancer Institute (NCI), in partnership with Northwestern University, developed an educational curriculum for clinicians who deal with end-of-life issues, the Education in Palliative and End-of-Life Care for Oncology. A live meeting was held to distribute the curriculum to institutional leaders who could take it back to their organizations for broader distribution. To further distribute the materials and ensure they were available whenever a clinician wanted to view them, NCI collaborated with a leading online medical education provider whose websites are visited by over 1,500,000 physicians per month ( http://cme.medscape.com ) to post one module of the curriculum as an online activity certified for physician and nurse continuing education credit. The module is entitled "Last Hours of Living: Practical Advice for Clinicians." A descriptive analysis of the first 7 months of publication was performed. Twenty thousand sixty-one health professionals completed the activity during this time period and earned continuing education credit. Eighty-four percent completed the post-activity evaluation survey. Satisfaction was very high among participants, and many indicated their intention to incorporate new knowledge into practice. Collaboration with a commonly used online medical education provider such as Medscape is effective at broadly disseminating palliative care education to health professionals.

Adaptation, Dissemination, and evaluation of A Cancer Palliative Care Curriculum for the Indian Health System

In 2006, the Indian Health Service (IHS) and the National Cancer Institute (NCI) collaborated to develop an interdisciplinary palliative training program for health professionals in the Indian health system. Their goal was to improve clinician knowledge and skills in palliative care, to train future trainers, and to increase access to palliative care for American Indians and Alaska Natives. The combined program of participant self-study utilizing a multimedia CD-ROM and train-the-trainer seminars followed the curriculum entitled Education in Palliative and End-of-Life Care for Oncology (EPEC-O) with American Indian and Alaska Native Cultural Considerations. Three seminars trained 89 interdisciplinary health providers from throughout the Indian health system. Evaluations demonstrated increased clinician self-reported knowledge and confidence to train and high satisfaction with training. Forty-two of 67 participants completed an anonymous post-conference Web questionnaire. Nearly half had conducted or definitively planned palliative education sessions, and 57 percent started new palliative services at their practice sites.

Palliative Care Education during Medical School: A National Survey of Medical School Deans and Graduating Students

I. Background. Medical students recognize the importance of palliative care education but currently receive inadequate training. Although medical schools are increasing tangible palliative care experiences, students’ perceptions of their preparation and practical skill continue to lag behind. II. Research Objectives. To determine academic deans’ perspectives on palliative care education compared to the teaching and attitudes to which graduating students report being exposed. III. Methods. A palliative care education survey, exploring domains of attitudes, practical knowledge, and sources of education, was distributed nationally to academic deans and senior medical students in Spring 2009. IV. Results. A total of 63 deans and 521 medical students completed the survey. Students felt less prepared to care for patients at the end-of-life than their overall preparation to provide patient care (P < .001). Asked whether residents/attendings considered dying patients to be good teaching cases for students, 18.4% responded ‘‘not at all,’’ while only 3.4% of deans reported the same response. A total of 20.7% of deans reported that faculty conveyed that working with dying patients is rewarding ‘‘a lot’’ compared to only 11.2% of students. When asked the extent to which students learn about end-of-life care from various providers, 28.9% of deans versus 53.3% of students reported the students learn ‘‘only a little’’ or ‘‘or nothing at all’’ from nonpalliative care attendings. A total of 41.4% of deans versus 77.6% of students report similarly limited learning from residents. V. Conclusion. Palliative education is receiving more attention in medical schools, but deans often overestimate their palliative programs. This survey reveals that attitudes to which students are exposed and the teaching received are inadequate to prepare the students for this aspect of practice. VI. Implications for Research, Policy, or Practice. This study illustrates the difference between the deans’ expectations of the palliative curriculum and the demonstrated deficits in palliative education that students actually receive.

Impact of the Education in Palliative and End-of-Life Care Project on Emergency Medicine Education and Practice

of preference and 12 PC educational topics in order of importance. IV. Results. Forty-two of 45 eligible participants completed survey (28 residents, 14 faculty). A total of 88% were less than 40-years-old. Respondents agreed/strongly agreed that PC skills are an important competence for EM (83%, 33/40) and that they would like to have more training/education in PC (93%, 37/40). They also disagreed/ strongly disagreed that PC is when no more can be done for the patient (90%, 35/39). Important PC topics identified were pain-management, discussing advance directives, and management of dyspnea or other symptoms in terminal illness. Bedside-teaching was the preferred modality, followed by simulation, and lastly lectures. EM residents (43% to 58%) reported minimal training in pain management, managing hospice patients, withdrawal/withholding life-support, and managing the imminently-dying. There was no significant improvement in any area from postgraduate year 1 to postgraduate year 4. V. Conclusion. EM physicians view PC skills as important for EM practice and report that they are not yet adequately educated and trained in PC. VI. Implications for Research, Policy, or Practice. PC physicians have already identified the emergency department as the upstream point where ideally more PC interventions and goals of care discussions should begin. Educating and training EM physicians in basic PC skills will enhance communication, increase their awareness of a patient’s PC needs, and serve to strengthen this partnership with PC.

A Strategy for Incorporating Palliative Care and End-of-Life Instruction into Physician Assistant Education

Physician assistant (PA) education has not historically taught end-of-life and palliative care in its curricula. While medical education has been reformed in the past 15 years to include palliative care, PA education lags behind. The Medical College of Georgia PA Program obtained a HRSA grant in 2009 to teach PA students about end-of-life issues and improve palliative education in the didactic and clinical years. Sparse published data exist for end-of-life/palliative education in PA programs. We built a Wiki Internet tool to help teach these concepts. We revised objectives in clinical medicine, emergency medicine, and surgery to improve instruction in end-of-life issues, including common symptom management. We extended the adult medicine clinical course from 4 weeks to 8 weeks to provide long-term care and hospice exposure. Students journaled their adult medicine experiences on the Palliative Care Wiki Discussion Forum. Students who participated in the Wiki Discussion Forum reported better understanding of end-of-life issues for patients who were near death or actively dying. Students expressed that bedside instruction, small groups, and hospice home visits were valuable venues for learning about end-of-life care. Students recommended more frequent and specific instruction in pain management and requested more time in hospice and critical care. Students appreciated learning from other students' experiences through the Wiki Discussion Forum. PA programs should incorporate palliative care and end-of-life instruction into existing curricula. Pain management and treatment of common end-of-life symptoms should be emphasized. Structured clinical experiences in critical care, hospice, and long-term-care settings should be offered.

A short palliative care experience: beginning to learn

The Robert Wood Johnson Foundation issued grants to establish palliative care clinical learning opportunities for medical students. We developed a 1-week focused curriculum on palliative care that was embedded into the internal medicine clerkship. We examined the feasibility of a 1-week course incorporated into the medicine clerkship, and looked at knowledge and attitudinal changes in students who had completed the course. In 2000, the Liaison Committee on Medical Education (LCME) mandated that all medical schools ‘must’ teach about end-of-life care, yet few schools have developed a comprehensive educational programme during a 4-year curriculum. The relatively recent American Board of Medical Specialties designation of hospice and palliative care as a medical subspecialty in 11 medical practice areas adds further motivation for medical schools to develop palliative care training for medical students. An extensive needs analysis was completed and a 1-week, required, comprehensive palliative care curriculum was developed for all Year 3 medical students during a 1-year period. The core curriculum was developed with the help of the Medical College of Wisconsin’s Medical School Palliative Care Education Project and the End-of-Life Palliative Education Resource Center. It included direct in-patient and out-patient care, multidisciplinary rounds, reflection exercises and didactic teaching around the core clinical topics of hospice and palliative care, pain management, dyspnoea, nausea and vomiting, constipation, delirium, anorexia, and depression and anxiety. It also included faculty development on core palliative care topics and the teaching of these topics. The programme was implemented for 1 year with grant support. Students in the last 9 months of the embedded palliative care course evaluated the programme. Programme evaluation included a survey of attitudes towards palliative care and pre- and post-course measurements of knowledge learned. Mean scores on the knowledge tests before and after the course were compared. A total of 53 of 84 (63%) students completed both pre- and post-tests. Students felt that learning palliative care was important to their education (100%) and that it was feasible to incorporate into a medicine clerkship (93%). All students felt it was useful to learn about palliative care. When knowledge was measured, mean scores were 145 (of 230 total points) pre-course and 175 post-intervention. The difference between the means is significant (P < 0.01), demonstrating that students had learned from the course. In conclusion, a 1-week palliative care course embedded in a medicine clerkship is feasible and effective for learning. As a result of this pilot project, a required, independent, 1-week palliative care clerkship and palliative care elective were instituted at our medical school.

A Case for Education in Palliative and End‐of‐life Care in Emergency Medicine

A Case for Education in Palliative and End‐of‐life Care in Emergency Medicine

Heart failure nurses’ experiences of specialist palliative care

Background : A key innovation in the care of patients suffering heart failure, who have palliative and end-of-life care needs, has been the introduction of specialist heart failure nurses. Aim : The aim of this article is to report and contrast the views and experiences of specialist heart failure nurses caring for patients with heart failure who are approaching the end of life in three settings in the UK. Sample : A purposive sample of heart failure nurses ( n =15) was recruited as part of a wider independent evaluation of the Marie Curie ‘Delivering Choice Programme’. Method : Three focus groups elicited information about the nurses’ roles, referral processes and working relationships with local hospice and palliative care services. Transcripts from the data collected in the focus groups were analysed using a modified grounded theory approach. Results : The uncertain trajectory of heart failure and the possibility of sudden death challenge models of palliative care developed in the context of cancer. Heart failure nurses from all three settings perceive that regular contact with patients for symptom management and supportive care prevents unwanted hospital admissions and provides carer support. The nurses welcome specialist palliative care advice and education but express concerns about overburdening local hospice services. Nurses report that, in their experience, many patients do not achieve their end-of-life care preferences because a wider network of support is lacking. Conflicts of interest: none

60. Using a pocket card to improve end-of-life care on clinical teaching units: A controlled trials

Although palliative and end-of-life is a critical part of in-hospital medical care, residents often have very little formal education in this field. To determine the efficacy of a symptom management pocket card in improving the comfort level and knowledge of residents in delivering end-of-life care on medical clinical teaching units, we performed a controlled trial involving residents on three clinical teaching units. &#x0D; Residents at each site were given a 5-minute questionnaire at the start and at the end of their medicine ward rotation. Measures of self-reported comfort levels were assessed, as were 5 multiple-choice questions reflecting key knowledge areas in end-of-life care. Residents at all three sites were given didactic teaching sessions covering key concepts in palliative and end-of-life care over the course of their medicine ward rotation. Residents at the intervention site were also given a pocket card with information regarding symptom management in end-of-life care.&#x0D; Over 10 months, 137 residents participated on the three clinical teaching units. Comfort levels improved in both control (p &lt; 0.01) and intervention groups (p &lt; 0.01), but the intervention group was significantly more comfortable than the control group at the end of their rotations (z=2.77, p &lt; 0.01). Knowledge was not significantly improved in the control group (p=0.07), but was significantly improved in the intervention group (p &lt; 0.01). The knowledge difference between the two groups approached but did not reach statistical significance at the end of their rotation.&#x0D; In conclusion, our pocket card is a feasible, economical educational intervention that improves resident comfort level and knowledge in delivering end-of-life care on clinical teaching units.&#x0D; Oneschuk D, Moloughney B, Jones-McLean E, Challis A. The Status of Undergraduate Palliative Medicine Education in Canada: a 2001 Survey. Journal Palliative Care 2004; 20:32.&#x0D; Tiernan E, Kearney M, Lynch AM, Holland N, Pyne P. Effectiveness of a teaching programme in pain and symptom management for junior house officers. Support Care Cancer 2001; 9:606-610.&#x0D; Okon TR, Evans JM, Gomez CF, Blackhall LJ. Palliative Educational Outcome with Implementation of PEACE Tool Integrated Clinical Pathway. Journal of Palliative Medicine 2004; 7:279-295.

Struggling in change at the end of life: A nursing inquiry

The purpose of this human science nursing inquiry is to explore the meaning of struggling in change for persons at the end of life. Guided by Parse's theory of human becoming, a descriptive exploratory method was used to answer the research question: What is the meaning of the experience of struggling in change for persons at the end of life? Eight persons who were living with dying described experiences of struggling in change during face-to-face audiotaped interviews. A process of analysis-synthesis revealed three themes that are discussed in relation to extant related literature and interpreted in light of the human becoming perspective. Findings from the study contribute new knowledge about human experience at the end of life from a human science perspective and offer new insights on struggling in change as a rhythmical pattern of living and dying. Implications for palliative practice, research, and education are discussed.

Clinical Social Work Education in Palliative and End-of-Life Care

This paper describes the first post-Master's program in the US in end-of-life care for social workers. Developed at the Smith College School for Social Work, this program used innovative relational methods in student recruitment, curricular design, supervision, and leadership development, based upon input from the faculty, students, and field supervisors. Collaborations emerged with funders, agencies, and programs nationally. The program was based on a pedagogical stance that clinical work with dying people requires the capacity to be fully present-in individual, group, and family work; in interdisciplinary meetings; and in advocating for quality and equity of care-while attending to diverse and at-risk populations. Students deepened their clinical skills and took leadership in the field of end-of-life care.

Palliative care and education in Uganda

Palliative care for people with chronic, life limiting, progressive conditions is a worldwide concern. Progressive illness is defined as long-term illness, that often limits daily activities and which medical interventions can control and not cure (Dowrick et al 2005). Progressive illnesses are the leading cause of death and disability (WHO 2004). Their rising incidence and prevalence creates major challenges for health and social services within individual countries and internationally (WHO 2002).

Promoting Effective Social Work Policy in End-of-Life and Palliative Care

Policy developments in the health care arena in general, and in end-of-life and palliative care in particular, strongly influence the practice environment for the delivery of hospice and palliative care services and the diverse roles of social work practitioners. This article analyzes policy developments in two crucial areas-ethics and law and disenfranchisement and health disparities. It focuses on the recent social work literature and other key sources and provides recommendations to promote the roles of social workers in ethics consultation, public policy, and advocacy and to integrate better the perspectives and concerns of diverse communities into palliative care practice, education, and policy.

Q-methodology: a systematic approach to assessing learners in palliative care education.

Q-methodology is a qualitative research method that has increasingly been used to identify the complex attributes and behaviors that impact learning within medicine. Because learners bring a lifetime of experiences, values, and beliefs to a palliative care education, this method is ideal for identifying the typology of learner's present, thus making it possible to adapt the palliative care curriculum to meet the identified needs of each subgroup of learners. A step-by-step overview of the methodology using an example from pediatric graduate medical education illustrates the process. Potential uses of Q-methodology in palliative care are outlined including its application to the assessment of affective learning competencies, before and after a palliative care curriculum. The development of a universal palliative care education Q-sample, a collection of subjective opinion statements reflecting the spectrum of opinions on the topic, would advance the use of the Q-methodology in palliative medicine education.

Prison hospice and pastoral care services in California.

Hospice at the California Medical Facility (CMF) Vacaville dates back to the mid-1980s, when the acquired immune deficiency syndrome (AIDS) epidemic began to be felt throughout California's Department of Corrections. Vacaville has served for decades as the principal location for delivering health services to California's incarcerated men. Informal hospice-like services were inspired by Elisabeth Kubler-Ross and through inmate and community calls for more humane care for dying inmates. By 1990, efforts to formally establish a hospice were under way. In 1996, a 17-bed, state-licensed hospice began caring for dying inmates. An interdisciplinary team plans and delivers the care, meeting weekly to admit and review patients. The Pastoral Care Services (PCS) inmate volunteer program, with more than 50 trained participants, provides care and comfort to dying patients in hospice and to ill patients on the general medicine service. PCS volunteers perform many duties, including sitting vigil with actively dying inmates. Inmates enrolling in hospice have to forgo further curative therapy, consent to the program in writing, and have a 6-month or less survival prognosis; patients are not required to have a do-not-resuscitate (DNR) order, but are encouraged to consider one. Training for physicians, staff and PCS volunteers is provided by the University of California, Davis faculty of the West Coast Center for Palliative Education. Bereavement services are provided for PCS volunteers, other inmate "family" and staff. Family and friends of the deceased in the free community are followed by phone, mail, and primarily through referral to resources in their local area.

Short Reports on New Approaches to Palliative Medicine Education

To paraphrase Mark Twain, “You may be on the right track, but if you aren’t moving fast enough you can still get run over.” Education in palliative medicine is on a fast track as educators are rapidly developing curriculum, assessment tools, and evaluation instruments in traditional and/or digital formats (e.g., CD-ROM, web, hand-held). To provide readers with the most recent information in the field of palliative medicine education, the Dilemma’s section will periodically publish selected “Short Reports on New Approaches to Palliative Medicine Education.” Modeled after the highly successful “In Progress” reports in Academic Medicine, each report will briefly describe an educational innovation that has been developed and piloted but is less than 3 years old. While this approach may limit the rigor of the project’s outcome data, it is offset by the decision to provide our readers with the newest approaches to palliative medicine education.

The Michigan Advanced Practice Nursing Palliative Care Project.

The emerging field of palliative care in the United States must respond to the health care needs of persons living and dying from advanced illness. The literature suggests that professional nursing education in palliative care is limited, inconsistent, and sometimes neglected. In response to these identified needs, the Michigan (MI) Advanced Practice Nurse (APN) Palliative Care Project was designed to integrate palliative education into existing graduate nursing curricula and to provide continuing education for postgraduate nurses.

Antemortem care in an afternoon: a successful four-hour curriculum for third-year medical students.

Numerous well-designed studies have shown that patients near the end of life often receive substandard palliative care. Medical students have expressed a strong interest in antemortem care; however, palliative medicine education remains poorly integrated into the overall curriculum at most medical institutions in the United States. In response to this need, a palliative medicine curriculum has been developed for medical students in the required third-year clerkship in family medicine at the University of Tennessee Health Sciences Center The implementation of this curriculum resulted in a statistically significant increase in student competence (as measured by a standardized pretest and post-test) and a significant trend in student confidence (as measured by a single-item Likert scale). The curriculum was popular with students, and encouraged many of them to request hospice clinical experiences during their family medicine clerkship, or to register for the elective fourth-year clerkship in palliative medicine.

Care at the end of life: a novel curriculum module implemented by medical students.

End-of-life (EOL) and palliative care education in medical school curricula stand at a crossroads. Consensus has emerged that these topics merit systematic instruction throughout medical school training, yet curricula all too often consist of sporadic lectures focused on bioethics instead of clinical skills. The medical student authors identified a deficit in their curriculum, and designed and implemented an EOL curriculum module for their colleagues. In early 2000 the authors surveyed senior medical students about their experiences with EOL and palliative education, identifying deficits in clinical training and recommendations for interventions. They then designed a case-based educational module to teach EOL communication skills to medical students commencing clinical training. Faculty with national and local experience with EOL and palliative care reviewed the curriculum. Twelve of these faculty were oriented to the curriculum and then taught it in pairs to groups of 12 to 16 medical students in 2000 and 2001. The curriculum develops skills, attitudes, and knowledge relevant for communicating bad news and establishing treatment options in the EOL setting by utilizing trigger videos, group discussion, role plays, and case discussions. Approximately 75% of the 86 eligible students attended the module in 2000 and 2001. Feedback has guided the curriculum's refinement by the medical student authors. In addition, a standardized patient exercise, introduced in 2001, allowed students to reinforce the skills learned during the module.