The Need for Improved End-of-Life Care Medical Education: Causes,Consequences,and Strategies for Enhancement and Integration

Abstract

End-of-life (EOL) care is a unique area of medicine that emphasizes holistic patient-centered care. It requires clinicians to consider a patients’ mental, emotional, spiritual, social and physical comforts and engage patients and their families in complex discussions and decisions. It is an area of medicine that requires sensitivity in communication in order to respond to a wide range of emotions from patients and their families. Given these intricacies, it is essential that healthcare professional trainees are exposed early in their careers so they can be better equipped to address EOL situations effectively. While many medical schools have integrated this important element in pre-clinical education, a formalized and standardized curriculum could allow for students to better engage in EOLcare scenarios that they will face as future physicians. In this editorial, we discuss potential strategies to incorporate EOL care didactics and experiential learning earlier in medical education as well as the consequences of inadequate EOL care education, particularly in medical schools, in its current state.

Introduction

Conversations about end-of-life (EOL) care are among the most complex, meaningful, and impactful discussions healthcare workers have with patients. Several studies have showcased the provider-perceived benefit of an interprofessional course on EOL care. Pereira et al. reported that a course on palliative and EOL care allowed healthcare providers to appreciate the nuances of EOL care with 96% of them indicating that the course was relevant to their practice. ¹ One might assume such trainings to be deeply rooted in the medical education system due to its challenging nature and profound impact on patients and caregivers. However, statistics say otherwise.^2-4 In the current state of EOL care education, 39% of medical students feel unprepared to help patients emotionally and 50% feel unable to address their own emotions on the topic. ⁴ Although a study by Dickinson et al asserted that a majority of medical schools in the US have incorporated some aspects of EOL care into the curriculum over the last several decades, the quality continues to be inconsistent, and the number of teaching hours are still lacking. ⁵ As medical students and faculty, we present our perspective on the need for a formal and robust EOL education in medical school as well as potential strategies for integration into medical school curricula.

Potential Causes of Lack of EOL didactics in Medical Education

There are several possibilities for the lack of adequate EOL training in medical school. Billings et al identify the etiology of this problem in a model that divides medical student education into 3 categories: formal, informal, and “hidden” curriculums. The formal curriculum is taught in the classroom setting such as lectures and organized workshops, while the informal curriculum is where students learn through direct clinical experience. EOL training has been found to be limited in both settings.^3,5,6 A study by Schmit et al demonstrated that only 4% of students participate in more than 10 EOL conversations throughout their education. ⁶ Furthermore, 35% of students have never experienced a patient being informed of a terminal prognosis. ³ Without a robust formal and informal curricula, the “hidden curriculum” has become the primary mode through which students gain familiarity with EOL education. The “hidden curriculum” refers to the learned attitudes and behaviors that are embedded in medical culture. In the context of EOL education, the “hidden curriculum” places an emphasis on providing acute care while death is viewed as a failure. This creates a culture where EOL care is not prioritized resulting in a lack of formal education and training. Additionally, providers may have their own unresolved feelings about death, which has led to the depersonalization of the patient and further avoidance of EOL conversations. Students are deficient when it comes to pain management, treating depression, and providing adequate attention and care to the feelings of dying patients as a result of learning primarily through the hidden curriculum. Furthermore, students who have more exposure to the “hidden curriculum” than the formal and informal curriculum were more likely to have a negative perception of EOL. ³ This impression not only results in an inadequate ability to provide EOL care but also deters many from pursuing palliative care as a specialty. This is concerning given that there is a current shortage of 6 000-18 000 palliative care physicians ⁷ , and this number is likely to increase.

Consequences of Inadequate EOL Medical Education

The resulting deficiencies of not addressing EOL care in medical school have grave consequences on patient care during residency training and eventual practice. Many residents do not receive additional training in this domain but actively engage in EOL care conversations, often with little supervision and opportunity for feedback to enable proficiency. ⁴ Without proper training, residents may not be equipped to handle the technical and emotional components that arise in EOL care, which negatively impacts their rapport with patients and caregivers. For example, a resident caring for a patient with terminal cancer may not be confident in engaging the patient and caregiver about EOL decisions. They might struggle to find the right words or adequately address the patient’s concerns or fears. This can lead to the patient feeling that the resident does not adequately comprehend their context, needs and emotions, ultimately compromising patient trust and comfort. This can result in patients disengaging with their care along with frustration on the part of the healthcare professional as well. The problem is further exacerbated by the fact that, due to their own inexperience, residents are limited in their ability to provide constructive feedback to medical students on how to appropriately have these difficult conversations with patients. This perpetuates a cycle where medical students are not prepared to provide EOL care and thus will be unable to train the next generation of students in residency.

Proposed Strategies to Enhance EOL Education in Medical School

To address these issues, it is essential to integrate EOL care education into medical school training curricula at the institutional level. Multiple model curricula that outline objectives and training requirements may be utilized by medical schools to ensure competency. ⁴ One effective strategy is to hold workshops before the start of clinical rotations, as a means for medical students to orient themselves on how to approach EOL care. This can be a didactic session as part of the medical school transition to clerkship curriculum, which should be followed by standardized patient encounters that require the medical student to engage with the patient in EOL care discussion. Additional sessions before selected clinical clerkships may also be incorporated. A workshop developed at Emory University for third-year medical students was shown to be effective in enhancing competency in topics such as advanced directives and managing pain. ⁸ Another approach could focus on medical students at the end of their fourth year. One such curriculum is the Transition to Residency, Internship, and Preparation for Life Events (TRIPLE) developed at Johns Hopkins School of Medicine. Through simulating EOL scenarios, the 7-hour curriculum prepared participants to feel more confident communicating difficult topics such as goals of care and advanced planning. It also improved competency in technical skills such as completing death certificates and discussing autopsy reports with patient families. ⁹ Furthermore, support and resources for medical students should be provided to manage the emotions they may face because of delivering EOL care. These resources could include counseling services, training in coping skills, debriefing sessions, and seeking support from peers or mentors.^2,3,8 Additionally, medical students should be encouraged to journal or write reflective essays about their experiences with EOL care and EOL discussions throughout their clinical years of medical school. Moreover, having a dedicated palliative care rotation in clerkship led by palliative care specialists and experts will help students apply the knowledge, skills, and abilities that they have acquired through both the formal and informal curriculum. Applying this approach will allow the students to grow more comfortable and confident in providing EOL care, preventing the hidden curriculum from becoming the primary mode of education. ¹⁰

It is also important to acknowledge the interdisciplinary nature of these conversations and have the support of social workers, chaplains, nurse practitioners, and psychiatry. Thus, along with a streamlined standardized curriculum on EOL care, we propose including a multidisciplinary panel to approach didactics in preclinical years. Having professionals from these fields would help to cover a wide array of topics, including advance directives, medical orders for life-sustaining treatment and physicians order for life-sustaining treatment. Additionally, students should learn how to engage in these conversations with the use of an interpreter as language barriers add an additional level of complexity to an already challenging area of medicine. Likewise, students should be well versed in cultural humility so they can understand the many different approaches and considerations for EOL care in our increasingly diverse society. Finally, there are several tools available to test the preclinical and clinical medical student attitudes toward the care of the dying, most recent being the 9-item version of the Frommelt Attitude Toward the Care of the Dying Scale (FATCOD-9IT) developed by Loera et al. ¹¹ Its reported validity and reliability could potentially be used as an assessment by medical schools to test the preparedness of students pertaining their aptitude regarding EOL care.

Conclusion

Overall, multiple resources and approaches can be developed or adapted to ensure that medical students are prepared to provide skilled and compassionate EOL care. Medical school leadership and administration must implement these strategies as it pertains to their specific medical school curricula. EOL education can be expanded through a combination of formal and informal learning opportunities, such as lectures, workshops, and clinical experiences. It is essential that while promoting EOL care education, medical school leadership also encourage conversations about death and dying within their communities in order to enhance medical student comfort and awareness about this area of medicine.