Teaching palliative care to critical care medicine trainees

OBJECTIVES: Palliative care is an important component of critical care medicine. Few fellowship programs have developed a curriculum designed to teach palliative care precepts to trainees. We describe our 2-yr experience in teaching palliative care to multidisciplinary critical care medicine fellows. DESIGN: Two-consecutive-year palliative care training for unselected critical care medicine fellows at a large, urban, university, tertiary care medical center. INTERVENTIONS: We 1) identified palliative care skills and knowledge that first-year critical care fellows should acquire; 2) developed a curriculum to teach those skills and knowledge, including required readings, small group lectures and skills sessions that included role-playing to modify skills and attitudes, and (in year 2) experiential learning on a hospital-based palliative care rotation; and 3) attempted to evaluate the curriculum with attitude and knowledge assessments. RESULTS: A total of 35 fellows participated in the palliative care training during the 2 yrs reported. Seven fellows participated in a clinical rotation in palliative care. Fellows evaluated usefulness of the small group sessions between 4.4 and 4.9 on a 5-point Likert scale. Four of seven fellows rated the clinical rotation quality at 3/5. Pretest and posttest knowledge mean scores were 58% and 69%, respectively. Problems included providing time for fellows to participate in the clinical rotation and negative attitudes regarding the relevance of palliative care to their future in critical care. CONCLUSIONS: Palliative care training for critical care fellows is feasible. Fellows value skills training more than a clinical rotation in palliative care. Baseline knowledge of palliative care is low.     

What indicators are measured by tools designed to address palliative care competence among ‘generalist’ palliative care providers? A critical literature review

Abstract

Background

There is growing evidence that generalists may lack skills and knowledge in palliative care provision. This has led to consideration of what the core competencies for palliative care provision among generalists should be.

Aim

The objective of this review was to present the best available evidence related to indicators of competence in palliative care provision.

Method

A systematic review of both qualitative and quantitative literature was undertaken. Medline, Medline in Progress, PubMed and CINAHL databases with additional hand searches of Journal of Palliative Care, Palliative Medicine, and the International Journal of Palliative Nursing were undertaken for the period 1990–2010. Hawker et al.'s checklist was utilized to select and assess data.

Results

Nineteen of the 1361 articles met the inclusion criteria. The reviewed articles suggest a number of indicators of palliative care competence including: medical knowledge/skills, perceptions of knowledge/skills, confidence in palliative care skills, attitudes/opinions towards palliative care, and experience in palliative care delivery. None of the reviewed research provided definitive evidence as to which indicators best reflect competency to practice.

Conclusion

Multiple approaches, combined in a strategy of triangulation, must be incorporated in any appraisal in order to successfully measure palliative care competence.     

Development of a medical subspecialty in palliative medicine: progress report

There is significant interest in seeking professional recognition of expertise in caring for people with serious life-threatening illness and their families through creation of a specialty in palliative medicine. Certification of physicians and accreditation of training programs are key elements for formal recognition. The American Board of Hospice and Palliative Medicine was established to achieve these goals. The next step in the maturation of the subspecialty of palliative medicine is to have both the certification and the accreditation recognized by the professional self-governing bodies in organized medicine. This paper answers common questions about obtaining recognition by the Accreditation Council of Graduate Medical Education, the American Board of Medical Specialties and its member boards. Formal recognition of the subspecialty of palliative medicine is sought in order to extend the knowledge and skills inherent in the domains of palliative medicine. Such recognition will also encourage more physicians to enter the field and assure standards of care for those patients and their families who need it.     

The Nordic Specialist Course in Palliative Medicine: evaluation and experiences from the first course 2003-2005

BACKGROUND AND AIMS: Palliative medicine is not recognized as a medical specialty in any of the five Nordic countries, but there is a great need for physicians with specialty qualifications to serve on an increasing number of palliative care services. The Associations for Palliative Medicine in the five countries agreed to develop a common Nordic course on a specialty level. RESULTS: A theoretical training course in six modules in two years was developed, based on the British palliative medicine curriculum and including a limited research project and a written exam. Twenty-two out of 30 students completed the first course as scheduled in 2005, and five more have obtained their course diploma later. The evaluation from the students showed very satisfactory personal experiences and subjective learning outcomes, and a positive influence on the overall development of palliative care in the respective countries. CONCLUSION: The Nordic Specialist Course in Palliative Medicine has proved a successful Nordic collaboration and may form the basis for a full specialist training programme.     

Enhancing the role of case managers with specialty populations: development and evaluation of a palliative care education program

Palliative home care is an important component of the care system for patients at the end of life and case management is considered an essential element of the Canadian home care system. Case managers play a critical role in allocating resources, thus influencing the costs and the viability of palliative home care. Case management education programs focused on care coordination with specialty palliative care populations are nonexistent. An education program targeted at improving the knowledge and skills of case managers in allocating resources to palliative care populations was developed and pilot-tested in a metropolitan Canadian city home care program. Core curriculum was based on an initial learning needs assessment and used case-based problem solving to enhance case-management skills. An improvement in knowledge was noted on posttests and case managers described increased comfort and confidence in their role as case managers to this patient population. Home care organizations caring for palliative care populations must ensure case managers are prepared for case management roles with specialty populations if the home is to be rendered an appropriate and viable care setting for patients at the end of life.     

Group supervision to support competency development in palliative care in Norway

AIM: to develop and evaluate a model of supervision created to provide continuous support throughout a 2-year postgraduate education programme. METHODS: twenty-five students attending the first 2-year postgraduate course in palliative care at the University College, Buskerud, Norway took part in a prospective study. A questionnaire was administered on five occasions: on commencement of studies, after 6 months, 12 months, 18 months and at the end of the programme. Student statements were analysed using methods of qualitative content analysis. RESULTS: students' appreciation of the value of supervision increased from the first to the last recording. Reflection and dynamic dialogue during group supervision were reported to be well-suited as methods of support in the development of insight into palliative care, integration of theory and practice, and development of skills. CONCLUSION: students stated that supervision confirmed knowledge, gave meaning and increased self-awareness in palliative care.     

Looking backward toward our future: creating the nexus between community health nursing and palliative care

Palliative care literature and practice have historically been dominated by end-of-life discussion, with palliative care often seen as the prequel to hospice care. As the population ages and previously fatal illnesses convert to chronic illnesses, the medically modeled, institutionally based care model is changing. Community health nurses (CHNs) are well equipped to play a role in this arena of care. They have a population-focused practice, experience with care in the community, an orientation to health, and skills related to advocacy and social justice. The authors outline salient issues in palliative care, exemplars of community-based palliative care programs, and the contributions CHNs can make toward development of an integrated model of care. A course of action is outlined for CHNs to pursue in this rapidly developing field and they are urged to participate in the next iteration of palliative care.     

Palliative care in Argentina: perspectives from a country in crisis

Argentina is a large South American country with a high prevalence of chronic disease-related mortality and a clear need for implementation of palliative care. Primary concerns related to palliative care are cultural, socio-economic and educational. Increasing poverty, patients and families receiving inadequate information about their diagnosis or prognosis, drug availability and costs, and insufficient knowledge by health care providers are obstacles to palliative care. Palliative care programs are developing throughout the country and methods by which they are meeting their needs are described. Several Argentinean palliative care initiatives are described and the role of the Pallium Latinomérica training program is discussed.     

The Business of Emergency Medicine: A Nonclinical Curriculum Proposal for Emergency Medicine Residency Programs

Over the course of their postgraduate medical education, physicians are expected not only to acquire an extensive knowledge of clinical medicine and sound procedural skills, but also to develop competence in their other professional roles as communicator, collaborator, mediator, manager, teacher, and patient advocate. Although the need for physicians to develop stronger service delivery skills is well recognized, residency programs may underemphasize formal training in nonclinical proficiencies. As a result, graduates can begin their professional careers with an incomplete understanding of the operation of health care systems and how to utilize system resources in the manner best suited to their patients' needs. This article proposes the content, educational strategy, and needs assessment for an academic program entitled The Business of Emergency Medicine (BOEM). Developed as an adjunct to the (predominantly) clinical content of traditional emergency medicine (EM) training programs, BOEM is designed to enhance the existing academic curricula with additional learning opportunities by which EM residents can acquire a fundamental understanding of the nonclinical skills of their specialty.     

Building capacity to provide palliative care in rural and remote communities: does education make a difference?

One strategy for improving access to palliative care services in rural and remote communities is to educate community-based health professionals in the knowledge and skills required to provide end-of-life care. It is, therefore, important to evaluate palliative care educational initiatives. This article provides an evaluation of the interdisciplinary education program at Lakehead University which aims to: improve the knowledge and skills of individual providers; contribute to the development of palliative care programs in rural communities; and develop palliative care trainers to educate their co-workers in the workplace. A survey of 353 providers who participated in the education program was completed after eight years of providing education. Results confirm that the goals of the education program were met, and that rural and remote communities reported a greater capacity to deliver palliative care. Nevertheless, respondents identified a lack of resources, especially home care visits, as an obstacle to improving care.     

Effects of a postqualification course in palliative care

AIM: This paper reports a study to determine the effectiveness of a postqualification course in palliative care in terms of increased knowledge, insight and self-efficacy among Registered and Licensed Practical Nurses. BACKGROUND: The importance of measuring the effectiveness of postqualification courses in palliative care for nurses is widely recognized. The benefits of such courses are often merely described in terms of satisfaction of the course participants. METHOD: A convenience sample of nurses was studied. The effect measurement comprised a pretest/post-test quasi-experimental design. Two instruments were used: a comprehensive variant of the Palliative Care Quiz for Nurses and an especially developed domain specific self-efficacy instrument for palliative care. These were used before and after the course. FINDINGS: The course had a positive effect on knowledge and insight level as well as on level of self-efficacy. The main improvements were related to pain and symptom management. Participants seemed to be able to increase the effects of the course by implementing certain products on the wards, such as clinical lessons, a pain assessment scale and relaxation massage. CONCLUSIONS: Palliative care courses can make a significant contribution to nurses' knowledge and insight, as well as their self-efficacy in providing palliative care.     

Design of a postgraduate course in palliative care

BACKGROUND: Although palliative care is multidisciplinary in nature, nurses play an essential role in terminal care. Because new nurses frequently lack the specific skills for palliative nursing care as well as competence in interdisciplinary practice, there is a need for continuing education in palliative care. This article describes a postgraduate course in palliative care for nurses. METHOD: A postgraduate course was developed based on the needs of palliative patients and the subjective and objective needs of nurses. FINDINGS: Four roles assumed by nurses in palliative care were identified: bureaucratic, biomedical, social-therapeutic, and informal. The actual results of the course were influenced by the contextual aspects, which were determined by the nursing environment. Assignments were formulated according to the needs of the nursing unit, and a number of peer review meetings were organized. CONCLUSION: Successful implementation of a postgraduate course in palliative care increases nurses' expertise and offers an opportunity for nurses to exchange experiences and search for solutions to problems together.     

A UK-wide postal survey to evaluate palliative care education amongst General Practice Registrars

OBJECTIVES: To evaluate the content of General Practice Registrars' (GPRs) palliative care education in the U.K. METHODS: Postal questionnaires were sent to 492 eligible GPRs across six purposively sampled U.K. postgraduate deaneries. RESULTS: GPRs were satisfied with their course coverage on control of pain, other symptoms and communication skills, and were also moderately confident in applying the knowledge gained in these areas. They showed a high level of knowledge in the management of cancer-related pain. There was less satisfaction with the coverage given to syringe driver use (38%) and bereavement care (36%), with fewer expressing confidence in applying their knowledge to these areas. CONCLUSIONS: GPRs have mixed perceptions about their palliative care education. Future educational packages should ensure that GPRs receive planned systematic training in bereavement care and some practical experience in the use of syringe drivers. Both Postgraduate General Practice Education departments and specialist palliative care providers should explore ways of working more closely together to provide GPRs with more expertize in palliative care.     

Palliative care and hospice programs

Palliative care and hospice programs are points on the continuum of comprehensive patient care. Unfortunately, provision of care for terminally ill patients is suboptimal. There are many new approaches to improving the skills of all physicians to fulfill the needs of patients, including better education for house staff, "train-the-trainers" programs for physicians in practice, research into methods of symptom control, and better access to established hospice programs. This review covers the history, current status, and practical suggestions for improving palliative care and hospice programs in primary care settings.     

A statewide status report on hospital-based palliative care programs

The Center to Advance Palliative Care (CAPC) has attempted to identify hospitals providing palliative care services in its 2008 state-by-state report, and currently through the web-based Palliative Care Provider Directory of Hospitals. To augment those efforts for one state, a survey was conducted to explore how many hospitals reported having palliative care services and how well those services met consensus recommendations. Survey results show that a majority (82?%) of hospitals continue to lack palliative care programs, and even knowledge of palliative care was limited. More education and training for physicians, health care staff, and the general public was recommended strongly.     

Hospice and palliative care: an expert interview with Louis W. Sullivan, MD. Interview by Perry G. Fine

At the National Hospice and Palliative Care Organization's 6th Clinical Team Conference on Hospice and Palliative Care, held April 21-23, 2005, in Atlanta, Georgia, Perry G. Fine, MD, Professor in the Department of Anesthesiology at the University of Utah in Salt Lake City and Vice President of Medical Affairs for the National Hospice and Palliative Care Organization interviewed Louis W. Sullivan, MD, former Secretary of the US Department of Health and Human Services and currently President Emeritus of Morehouse School of Medicine, Chair of the Sullivan Commission-a commission to increase diversity among health professionals, Chair of the National Health Museum, Cochair of the President's Commission on HIV/AIDS, and Chair of the President's Commission on Black Colleges and Universities, as well as Chair of Medical Education for South African Blacks. Dr. Fine and Dr. Sullivan discussed the importance of hospice and palliative care, along with some of the practical issues facing clinicians who wish to use the hospice care system.