Improving Palliative Care for Cancer (2001) / Chapter Skim
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9 Professional Education in Palliative and End-of-Life Care for Physicians, Nurses, and Social Workers
9 Professional Education in Palliative and End-of-Life Care for Physicians, Nurses, and Social Workers
Pages 277-310
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From page 277... ...
However, it also reported "increasing acknowledgement by practitioners and educators of the compelling need to better prepare clinicians to assess and manage symptoms, to communicate with patients and families, and to participate in interdisciplinary caregiving that meets the varied needs of dying patients and those close to them." The increasing interest had already translated into new programs by professional societies, medical schools, and private foundations, and these continue. However, impressive as the initiatives are, they are small in scale compared with national needs.
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From page 278... ...
Perhaps even more persuasive is the complete lack of documented disagreement about the poor state of end-of-life medical education.
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From page 279... ...
Results for undergraduate medical education and residency programs are summarized separately. Undergraduate Medical Education Two surveys provide information on medical school curricula: the Liaison Committee on Medical Education (LCME)
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From page 280... ...
AAMC MEDICAL SCHOOL GRADUATION QUESTIONNAIRE The AAMC annual survey asks graduating medical students to rate the adequacy of instruction in various areas. In 1998, they were asked about death and dying, and pain TABLE 9-1 LCME Annual Medical School Questionnaire Course Content ~ 125 Schools = 100 % ~ Type of Course Required Course No.
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From page 281... ...
Of the types of physicians most likely to care for dying patients · 92 percent of programs in family practice and internal medicine and 98 percent in critical care medicine reported positively, and · between 60 percent and 70 percent of programs in obstetrics-~vnecology, pediatrics, psychiatry, and surgery reported positively. The results of these recent surveys suggest that undergraduate medical and residency training lacks adequate content in end-of-life care, but without much detail.
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From page 282... ...
searched the published literature for articles on palliative care and related topics for the years 1980 through 1995 and reviewed palliative care education grants funded by the National Cancer Institute or submitted for funding to the Project on Death in America. One hundred eighty articles culled from more than 9,000 potentially relevant citations form the basis of their analysis.
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From page 283... ...
Their findings span research published from 1980 through 1995; thus, some findings may be less relevant in 2001 than when published, but the pace of change has not been so great that this is necessarily so. Following are some provocative observations from individual studies: · 30 percent of a random sample of generalists in Oregon recalled medical school training in dealing with dying patients, and 87 percent thought that more such instruction should be given in medical school; · 39 percent of a sample of young physicians felt they had good or excellent preparation for managing the care of patients who want to die; · 41 percent of students completing third-year clerkships were never present when an attending physician talked with a dying person, 35 percent had never discussed with an attending physician how to deal with terminally ill patients, 73 percent had never been present when a surgeon told a family about bad news after an operation, and one-third could not identify problems that would arise for family members when a dying patient was discharged to go home.
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From page 284... ...
According to the limited information available, most end-of-life training is provided in lectures only. Contact with dying patients, particularly for undergraduate medical students, if any, is limited.
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From page 285... ...
However, "the best TABLE 9-4 End-of-Life Care in General Medical Textbooks Diseases Studied Content Domains AIDS Epidemiology Dementia Prognostic factors Chronic obstructive pulmonary disease Disease progression Congestive heart failure, chronic renal failure Medical interventions that change Cancer: breast, lung, pancreas, and colon disease course Cirrhosis Advance care planning Diabetes Mode of death Stroke Decisionmaking Effect of death and dying on patient's family Symptom management SOURCE: Carron et al., 1999.
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From page 286... ...
was the subject of the second major review (Rabow et al., 2000~. The methodology followed closely the methods used by Carron and colleagues in their study of general medical textbooks, but the content domains were expanded and the medical conditions studied necessarily varied from book to book and were chosen to represent the common causes of death in each specialty.
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From page 287... ...
Pain management Nonpain symptom management (dyspnea, nausea and vomiting, delirium, fatigue, etc.) Geriatric Psychological issues (depression, anxiety, fear, medicine (5)
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From page 288... ...
oncologists about their experiences in providing care to dying patients. The questionnaire consisted of 118 questions about end-of-life care under eight headings, one of which was education and training (Hilden et al., 2001~.
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From page 289... ...
Traumatic patient experiences ranked higher as a source of learning than did lectures during fellowship, medical school role models, and clinical clerkships. Recommendations to Improve End-of-Life Medical Education In 1997, the Robert Wood Johnson Foundation and the Project on Death in America brought together 94 academic leaders (selected through a structured nomination process)
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From page 290... ...
3. Medical education should encourage students to develop positive feelings about dying patients and their families and about the role of the .
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From page 291... ...
Programs and Activities Needed to Advance End-of-Life Medical Education2 Faculty Development Few medical faculty, at either the undergraduate or the graduate level, are knowledgeable and enthusiastic about end-of-life care and therefore are not likely to be effective teachers. To compound this, there is little end-oflife care included in the grand rounds, teaching conferences, or journal clubs of traditional continuing medical education (CME)
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From page 292... ...
Students should experience working together with physicians of different specialties, nurses, social workers, psychologists, other mental health workers, and clergy. They should also be instructed in caring for, and have opportunities to interact with, dying patients and their families (Weissman et al., 1999~.
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From page 293... ...
Improving the Research Base for Palliative Care Education In addition to the many unanswered clinical questions surrounding end-of-life care, there is research to be done that could directly benefit the education process. The "epidemiology of dying" would describe where, how, and under whose care patients die in different settings, including the interactions of physicians, nurses, social workers, clergy, family, and other caregivers.
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From page 294... ...
The format consists of four 30-minute plenary modules and twelve 45 minute workshop modules. Harvard Medical School Palliative Care Education Center 711198-6130103 $997,873 from RWJF Stanford University Medical School Faculty Development Program 1 011198-9130102 $831,931 New York State Medical School Curricula Project in Palliative Care 3115199-9114100 $268,792 Center for training faculty from around the country in palliative and end-of-life care Train-the-trainer program for medical faculty from across the country Developing a consensus on core curriculum for all medical schools in the state that schools will begin to incorporate into their programs.
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From page 295... ...
An educational partnership among the Division of Primary Care of Harvard Medical School (HMS the Department of Ambulatory Care and Prevention of HMS and Harvard Pilgrim Health Care, the Brigham and Women's Hospital, the Dana Farber Cancer Institute, and Massachusetts General Hospital to develop and implement a Palliative Care Role Model Program to train clinical leaders in these institutions.
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From page 296... ...
The learning experiences will be provided as part of the required curriculum and as elective coursework and will involve both classroom and clinical experiences. Renewal of project whose long-term goals are to design, implement, evaluate, and institutionalize a comprehensive program of hospice and palliative care education at the University of Maryland School of Medicine for medical students and physicians (residents and faculty)
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From page 297... ...
The current study is developing and implementing the SCIM for medical students, with the teaching of clinical skills critical to the diagnosis and multidisciplinary management of the cancer pain patient. To promote physician competence in end-of-life care by developing practical, clinically oriented educational materials that can be used in training medical students, residents, and practicing physicians to care for dying patients.
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From page 298... ...
Nurses were found to have had little supervised clinical experience with dying patients and had been given minimal guidance on handling their personal reactions and involvement with dying patients. Criticisms were also raised that the end-of-life curriculum is out of date and not based on current models of death education.
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From page 299... ...
C`Critical content areas" were identified as key items that should appear in complete discussions of each content area (the pharmacology texts were treated somewhat differently, appropriate to their different scope) , and included: Palliative care defined Quality of life Pain Other symptom assessment and management Communication with dying patients and their family members Role/needs of caregivers in end-of-life care Death Issues of policy, ethics, and law Bereavement
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From page 300... ...
. l tarriers to pain management; fear of opioids hastening death or opioids near death; equianalgesia; and recognition of nurses' own burden in pain management.
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From page 301... ...
SOCIAL WORK EDUCATION IN END-OF-LIFE CARE Social workers are central to counseling, case management, and advocacy services for the dying and for bereaved families. With their focus on
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From page 302... ...
The goal is to create a comprehensive end-of-life curriculum for nurses, which will be implemented in this project; by 450 undergraduate nursing programs, 225 continuing education providers, and the 100 state boards of nursing. NOTE: EPEC = Education for Physicians on End-of-Life Care; RWJF = Robert Wood Johnson Foundation.
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From page 303... ...
Quite recently, opportunities have been identified, and some programs initiated, to begin making the needed changes. End-of-Life Care Training in Social Work Educations Studies in the 1990s began to look at the end-of-life content of social work education and the preparedness of social workers to care for dying patients and their bereaved families.
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From page 304... ...
the extent of social work educators' experiences in teaching and research in bereavement and end-of-life care. The first survey involved 48 oncology social workers attending the 1998 annual meeting of the Association of Oncology Social Workers.
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From page 305... ...
They reported that they were aware of no money targeted specifically for end-oflife research in social work. Opportunities for Improving Social Work End-of-Life Education Some specific areas that could benefit from funding and development of programs are · better undergraduate and master's level curricula in end-of-life care; · innovative programs that integrate coursework with clinical work through alliances between schools and practice sites; · accessible continuing education designed and provided by social work experts in end-of-life care; and · collaborative educational programs with other professions working with dying patients and bereaved families.
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From page 306... ...
Improved Educational Materials New materials have to be created and existing materials improved for training new and practicing physicians, nurses, and social workers. This includes adding end-of-life content to textbooks, producing pocket guides and other references, and developing continuing education materials for practicing professionals.
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From page 307... ...
Students should experience working together with physicians of different specialties, nurses, social workers, psychologists, other mental health workers, and clergy. They should also be instructed in caring for and have opportunities to interact with, dying patients and their families (Weissman et al., 1999~.
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From page 308... ...
Improving the Research Base for Palliative Care Education In addition to the many unanswered clinical questions surrounding end-of-life care, there is research to be done that could directly benefit the education process. The "epidemiology of dying" would describe where, how, and under whose care patients die in different settings, including the interactions of physicians, nurses, social workers, clergy, family, and other caregivers.
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From page 309... ...
Billings, JS, Block S Palliative care in undergraduate medical education.
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From page 310... ...
Preparing social workers for the inevitable: A preliminary investigation of a course on grief, death, and loss. Journal of Social Work Education 1998;34(2)
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