Undergraduate Curricula in Palliative Medicine: A Systematic Analysis Based on the Palliative Education Assessment Tool

Abstract

Background:

By law in 2013, palliative medicine will be integrated into the undergraduate curriculum as part of a mandatory training program and examinations at German medical schools. For this reason a national curriculum in palliative medicine has to be developed.

Aim:

The aim of this study was to analyze international undergraduate curricula in palliative medicine, and thus support further curriculum development in Germany.

Design:

Available international curricula were sought through general search engines (Google, Medline/Pubmed) in German and/or the English language. We used the palliative care education assessment tool (PEAT) for analysis of available curricula. The PEAT comprises 7 domains, and 83 objectives.

Results:

We identified 17 international undergraduate curricula on palliative medicine. There was a wide variation in curricular design. Mapping the curricula, the results showed that five of the seven PEAT domains were represented in the curricula retrieved. Sixteen objectives were included in more than 75% and 46 objectives in up to 50% of the curricula, respectively. Eighteen objectives were included in less than 25% of the curricula. Three PEAT objectives were absent in all curricula examined.

Conclusion:

There is an overlap between objectives presented in the PEAT and in the curricula, suggesting that there are “core objectives” such as “respect for differing values,” “bereavement process,” and “use of opioids” which might be mandatory for undergraduate palliative medical education.

Introduction

Major international deficits in the visibility of palliative medicine in undergraduate medical curricula have been identified and robustly described across Australia, Europe, and America.¹ The European Association for Palliative Care (EAPC) stresses that training in palliative care in medical schools has a major impact on the future of palliative medicine (PM) and that shortcomings in medical education can hinder delivery of good palliative care to patients. At present, clinical care in PM is largely directed towards those suffering from malignant disease. However, the vast majority of patients with chronic disease, who would benefit from palliative care services, are unable to access such services by virtue of their diagnosis. There is clearly a great need for universal access to palliative care.² Offering basic PM training for every medical student would help to overcome such challenges, since the goal of undergraduate palliative medical education is to gain proficiency in the application of basic principles of palliative care knowledge, relative to the primary care or hospital setting.³ In Germany, a turning point in palliative medicine undergraduate education will take place in 2013. Palliative medicine will be integrated into the undergraduate curriculum (UC) as part of mandatory training and examination at all German medical schools.⁴ For this reason, a universally recognized UC in palliative medicine should be developed on a national basis.⁵

To facilitate the process of curricular development for mandatory training in palliative medicine in Germany, we undertook a study to present the current status of international UC through a systematic comparison of available curricula. To the best of our knowledge, the Palliative Education Assessment Tool (PEAT) offers the first and the only systematic review of content in palliative care, which can be integrated into medical schools' UC. The PEAT was developed in 2000 to facilitate and ease curricular mapping of education on palliative care.⁶ The PEAT comprises 7 domains (I-VII), which are further subdivided into a total of 83 objectives. The domains include the following topics: I, palliative medicine (6 objectives); II, pain (12 objectives); III, neuropsychological symptoms (11 objectives); IV, other symptoms (10 objectives); V, ethics and the law (20 objectives); VI, patients/family/caregiver nonclinical perspectives on end-of-life (EOL) care (12 objectives); and VII, clinical communication skills (12 objectives). The aim of this study is therefore to analyze UC by using a standardized instrument for the mapping of curricular content.⁷

Methods

Step 1

The study was designed by applying a stepwise approach. Step 1 included a comprehensive strategy to search the literature for all available undergraduate curricula (UC) in medicine. The eligibility criteria for UC were relatively broad to include all potential resources. All UC required the presence of core items, whether in the form of a syllabus, learning objectives, and/or core competencies. The timeline was restricted to the last two decades. The literature search was carried out in two languages: German and/or English. The search engines Google and Medline/MedPilot/PubMed were used, by entering the following medical subject headings terms: palliative medicine, palliative care, end-of-life care, in combination with additional terms curriculum, curricula, syllabus, undergraduate education, guidelines, medical school, medical student. Selection included all available curricula including online presentations of palliative care programs as part of website data from various medical schools. We contacted named authors for additional information, in case published data did not provide enough detail, e.g., where the curriculum was presented as a theoretical proposition rather than one currently integrated and evaluated.

Step 2

From all available UC, baseline data were extracted, including year of publication, source, country, editor, institution, length of publication, topics, assessment methods, duration of program, and purpose of the UC.

Step 3

For further evaluation of the data, the curricular content was mapped with a standardized instrument for evaluation of undergraduate medical teaching. As part of the evaluation of quantitative data, we calculated the frequency of domains and objectives, which were mentioned in the different syllabuses or curricular content of UC. We present the results, using the frequency expressed as a percentage of those objectives enlisted in the PEAT, which are included in the available UC.

Results

We identified 17 undergraduate palliative care curricula from Australia (n=2),^8–10 Canada (n=3),^11–13 Europe (n=6),^14–20 and the United States (n=6);^21–29 47% of these were designed for national and/or international use, 53% for local use at a specified institution. Table 1 summarizes data on the undergraduate curricula.

Table 1.

Characteristics of All Retrieved Undergraduate Curricula 1–17

Number	Year of publication	Country	Title (short version)/feature	Topics specified	Specific learning objectives (yes/no)	Assessment methods specified (yes/no)	Time line and duration of program	Purpose of the UC
1	1993	Canada	The Canadian Palliative Care Undergraduate Curriculum¹³	Symptom control: pain, mouth care, dyspnea, sleep disorders, nausea, vomiting, constipation, bowel obstruction, genitourinary symptoms, anorexia, decubitus ulcers, lymphedema, confusion, anxiety and depression; Psychosocial issues: communication with patient and family, social impact of illness, cultural issues, spiritual issues, alternative/unorthodox therapies, death awareness; Fundamental issues: ethical issues, home care of dying patients, cost containment and quality assurance	Yes	no	not specified	international (global)
2	1993	Europe	Curriculum for Undergraduates/Palliative Medicine Syllabus for Medical Student¹⁷	Physical aspects: disease process, symptom control, pharmacology; Psychosocial aspects: family and social background, communication skills, psychological responses, sexuality, grief, awareness of professional and personal feelings; Religious and cultural aspects; Ethical aspects; Teamwork; Organizational aspects (statutory regulations)	no	no	during clinical years as a single block or over three years	international (Europe)
3	1996	Australia	Australasian Undergraduate Medical Palliative Care Curriculum⁸	Pain; Nausea and vomiting; Respiratory syndromes; Bowel care; Mouth and skin care; Cognitive, mood, and sleep disorders; Oncological emergencies; Palliative care for nonmalignant conditions; Palliative care in HIV/AIDS; Pediatric palliative care; Psychosocial and spiritual support; Terminal care; Home care; Doctor's duties after death; Communication skills; Ethics; Grief and bereavement; Multidisciplinary team work and volunteers; Emotional self care for doctors	yes	no	embedded in the complete period of medical education (vertical integration: early years (one, two) attitudes and ethics; middle years (three, four) knowledge: basic science and clinical; final years (five, six) skills: practical management	national
4	1999	Canada	An interdisciplinary approach to a day-long palliative care course for undergraduate students¹²	Roles of various health care professionals in palliative care; Features necessary for interdisciplinary teamwork; Issues involved in caring for patients in palliative care and their families; Principles and means of pain management and symptom control; Thoughts, feelings, and values associated with various palliative care situations; issues involved in grieving and bereavement; Importance of caring for oneself as a health care provider and provide some strategies for doing so	yes	no	1 day	local
5	2000	U.S.	A collaborative EOL care curriculum²¹	History/philosophy of hospice and palliative care; Death and dying/dying process; Communication skills; Meet liaison nurse/admissions coordinator, mentor; Spiritual core lecture; Ethics, process group; Pain management; Chemotherapy in palliative care, radiation; Documentation lecture; Management of other symptoms; Interdisciplinary team-NHO standards of care, Interdisciplinary team meeting; Alternative and complementary therapies; Grief and bereavement; Care of the caregiver; Physical assessment; Home visits; Ethics committee; Inpatient hospice rounds; Daily precepting with hospice medical director; Support group for hospice staff; Complementary therapies; Rural involvement; Cultural diversity, Religious diversity; Pediatric hospice care	no	no	4 weeks	local
6	2001 (publication), continuous online update	Maryland, U.S.	Institutionalization of a Palliative and End-of-Life Care Educational Program in a Medical School Curriculum^25,26,27	Psychosocial aspects of death and dying; Understandings of physiology and management of common EOL symptoms; Common symptoms; Psychosocial/technical/cultural/spiritual aspects, impact of illness, ethical issues; Mission, definition, philosophy of hospice; Definition of unit of care; Palliative/hospice care; Role of primary care physician [publication]; ANALYZE the value of palliative/hospice care as a component of practice in managing specific patient problems; DEMONSTRATE a compassionate approach to the care of patients with terminal illness; DESIGN, in cooperation with the interdisciplinary hospice/palliative care team, a comprehensive plan of care for a patient with a terminal illness; Behavioral objectives: Pain and nonpain symptom management, Management of symptoms other than pain, Opioid conversion exercise, Aberrant drug behaviors, psychosocial dimensions, spiritual issues	yes	yes	20 hours (as part of med school curriculum)	local
7	2004	New Mexico, U.S.	A proposed Curriculum for Teaching Palliative Care at the University of New Mexico Health Sciences Center²³	Communication; The family (Identifying the family and their role in EOL care); Ethical issues (the physician and the ethical principles that we face); Symptom management (the physician and symptom relief); Disease trajectory (predicting survival and its discussion); Spiritual issues (culture, religion, and their role in the family); Settings (how to work outside the medical center); The family (the unit of care); The legal issues (Knowing the rules)	yes	no	embedded in the complete period of medical education	local
8	2005	Australia	Principles for including palliative care in undergraduate curricula/Palliative care in undergraduate curricula^9,10	Principles of palliative care; Palliative assessment & intervention; Optimizing function in palliative care; Coping with dying and bereavement; Principles for assessment and management of clinical and supportive care needs; Communicating with people with life-limiting illnesses (loss and grief, existential challenges, uncertainty, changing goals of care); Diversity (patient needs and preferences, practice settings, illness conditions, sociocultural contexts)	yes	no	not specified	national
9	2006	Great Britain, Ireland	Consensus Syllabus for Undergraduate Palliative Medicine in Great Britain and Ireland (Based on the APM curriculum)²⁰	Basic principles; Physical care (disease process, pharmacology, symptom management, care of the dying patient, rehabilitation); Psychosocial care (psychological responses, communication with patients and relatives, social and family relationships, grief and bereavement, personal and professional feelings); Culture, language, religious, and spiritual issues; Ethics; Legal frameworks	yes	no	embedded in the complete period of medical education; horizontal integration encouraged	national
10	2006	Canada	EFPPEC. National Consensus on Undergraduate competencies in medical education/Pan-Canadian Consensus on undergraduate curriculum¹¹	Pain and symptom management; Psychosocial and spiritual needs; Bioethical and legal framework (EOL decision making); Communication (patients, families, other caregivers); Interdisciplinary team; Suffering	yes	MCQ, OSCEs (with standardized patients), observation of clinical performance	embedded in period of medical education, pre-clerkship and clerkship years	national
11	2007	Europe	Curriculum in Palliative Care for Undergraduate Medical Education¹⁸	Basics of palliative care; Pain and symptom management; Psychosocial and spiritual aspects; Ethical and legal issues; Communication; Teamwork and self-reflection	no	Formative assessment (e.g., self- assessment, assess-ment by supervisor), Summative assessment (exam, e.g. MCY, oral)	total of 40 hours in different years of undergraduate education, with basics as early as possible	inter-national
12	2007 (publication), continous online update	Yale/Connecticut, U.S.	Palliative and EOL care education. Curriculum. Yale School of Medicine^22,29	Physical symptoms; Psychosocial aspects; Spiritual aspects; Professional and personal challenges of caring; Self-reflection; Communication; Pain and symptom management; Role of culture and spirituality; Interdisciplinary team; Palliative medicine in emergency setting; DNR order; Death pronunciations, death notification; Hospice care/hospice elective	yes	Online evaluation (written reflection)/question-naire	4 years, embedded in the period of medical education	local
13	2008?	Stanford/California, U.S.	End of Life Online Curriculum²⁸	Modules: Overview of palliative care; Opioid conversion; Palliative sedation; Dyspnea; Prognostication; Communication; Home hospice; Transition to death; Bereavement	yes	Online evaluation/questionnaire	not specified, self-directed learning (online)	local, also national
14	2009	Germany	Curriculum on Palliative Medicine for Undergraduates¹⁶	Basic principles; Pain and symptom control; Psychosocial aspects; Ethical and legal aspects; Perception and communication; Teamwork and self-reflection	no	Formative assessment (e.g., self assessment, assessment by super-visor); Summative assessment (exam, e.g., MCY, oral)	40 hours (minimum of 20 hours) embeded in the period of medical education	national
15	2009/2010	Edinburgh, Scotland, U.K.	Palliative Care Learning outcomes for Medical Students/Palliative Care Teaching for Undergraduates^15,19	EOL management (including management of symptoms, practical issues of law and certification); Ethics; Communication and teamwork; Holistic care; Bereavement (including adaptation to major life changes such as bereavement including abnormal adjustments that might occur); Tertiary disease prevention; Patients needs and families needs assessment, patients rights; Drug therapy for pain and other common symptoms, pain management; Services/structures of palliative care in the UK; Life cycle	yes	no	embedded in period of medical education (years 1–5)	local
16	continuous online update	King's College London, U.K.	Undergraduate Curriculum in Palliative Care¹⁴	Symptom control; Dying patient; Nutrition, anorexia, and cachexia in advanced cancer, Ethics in withholding and withdrawing of treatment in advanced cancer; Generic palliative care SSC	yes?	not specified	embedded in period of medical education	local
17	2011	Ohio, U.S.	A 4-year Integrated Curriculum in Palliative Care for Medical Undergraduates²⁴	Introduction to hospice and palliative care; Pain and symptom management; Advance directives; Pediatric cancer and palliative care; Competency and goals of care; Grief and bereavement; Pediatric IDT; Geriatric patients and families; Dialysis patients and spouses; AIDS patients; Literature on death and dying; EOL physician and patient relationship; Breaking bad news; Cadaver memorial service; Epidemiology of death; EOL nutrition and hydration; Family medicine hospice experience; Dementia and family caregiving; EOL case/breaking bad news; Family meetings; EOL medical management; Home hospice care, hospice IDT	yes	exam questions	embedded in period of medical education, preclinical year, and clinical years (1–4)	local

APM, The Association for Palliative Medicine of Great Britain and Ireland; DNR, do not resuscitate; EFPPEC, Educating Future Physicians in Palliative and End-of-Life Care; EOL, end of life; IDT, interdisciplinary team; MCQ, multiple choice question; MCY, major clinical year; NHO, national health organization; OSCE, objective structured clinical examination; PEAT, palliative education assessment tool; UC, undergraduate curriculum.

There was wide variation in curricular structure, both in presentation of specific core items and in the overall purpose of the UC. Core items were presented as a syllabus, with or without learning objectives and/or core competencies. For example, Educating Future Physicians in Palliative and End of life Care (the EFPPEC joint project)¹¹ (Table, #10) provides a detailed selection of core competencies, representing the Pan-Canadian national consensus on undergraduate competencies in medical education. Therefore, EFPPEC no longer uses just a syllabus of palliative care terms. An early UC from Canada in 1993, (table, #1) provides clearly stated learning objectives.¹³ However, this curriculum only provides preliminary exemplary data, because the authors intended to present principles on how to design a UC on a national and international basis.

Similarly, the UC from Germany and the EAPC from 2007 (table, #11, #14) provide recommendations and instructions for further national and international curricular design.^16,18 Further, the UC identified from Australia (table, #3, #8) is also designed for national use, providing principles for including palliative care in undergraduate curriculum.^8,9 Therefore, given the national and/or international focus of these curricula, all the above offer a potential template for national UC development in Germany.

UC from the United States (table, #5–7, #12–13, #17) present content designed specifically for implementation in medical schools.^21–25,28 Most refer to additional data such as formative and summative teaching material attached to the UC. Some of the learning materials can be accessed online, for example UC #6 and #12.^26,27,29 The UC from Stanford University (#13) is one example of an UC, which is essentially designed for online use.²⁸

Similarly, the UC from Great Britain, #15–16, is designed for use at medical schools in Edinburgh, and London.^14,15,19 On request, the authors provided additional data, which is not yet published. These data include learning objectives, syllabi, and additional teaching material.

PEAT-based analysis

The next step shows the result to the mapping process of all items enlisted in the PEAT with the curricular set. We identified one UC, which recommended the PEAT for use as a draft in further curricular development (table, #11).¹⁸

Regarding the overlap between PEAT domains and content of the UC, there was 100% representation for five of the seven PEAT domains (DII, pain; DIV, other symptoms; DV, ethics and the law, DVI, patients/family/caregiver nonclinical perspectives on EOL care; DVII, clinical communication skills). DI, palliative medicine, was represented by 16/17 curricula and <D–number?>(neuropsychological symptoms) by 14 curricula.

In more than 75% of UC, 16 PEAT objectives of DI (palliative medicine), DII (pain), DIV (other symptoms), DV (ethics and the law), DVI (patients/family/caregiver nonclinical perspectives on EOL care), and DVII (clinical communication skills) were included. The number of specific objectives per domain was variable, ranging from one to five, with the highest number reflected in DVI and DVII specifically, clearly demonstrating their importance to the discipline. Additionally, the three PEAT objectives most often mentioned in the UC could be attributed to these domains: values history (DVI), bereavement process (DVI), and respect for different values (DVII) (see Fig. 1).

FIG. 1.

Percent overlap of PEAT objectives and the undergraduate curricula 1–17. PC, palliative care; PEAT, Palliative Education Assessment Tools.

Forty-six of the 83 PEAT objectives were included in more than 50% of the UC. Notably, these reflected PEAT domains DI (palliative medicine, 6 objectives, 100% of all objectives in DI); DVII (clinical communication skills, 9 objectives, 75% of all objectives in domain DVII); DIV (other symptoms, 7 objectives, 70% of all objectives in DIV); DII (pain, 8 objectives, 66% of all objectives in domain II); DVI (patients/family/caregiver nonclinical perspectives on EOL care, 7 objectives, 58% of all objectives in DVI); and DV (ethics and the law, 9 objectives, 45% of all objectives in DV). Less than 50% of analyzed UC referred to any PEAT objective in DIII (neuropsychological symptoms).

Of the 18 PEAT objectives included in 25% or less of the UC, 9 objectives and 8 objectives were attributed to DIII (neuropsychological symptoms, 82% of all objectives in DIII) and DV (ethics and the law, 40% of all objectives in DV), respectively. The one remaining objective belonged to DVI (patients/family/caregiver nonclinical perspectives on EOL care).

Three objectives of PEAT DIII and DV were not found at all in any of the 17 UCs. The topics of these objectives were: procedures on newly deceased, definition of brain death, and efficacy of neuropsychological management.

Discussion

The authors of the PEAT have demonstrated that their assessment tool for curricular mapping of palliative care education has been successfully applied to facilitate curricular planning and upgrading within medical schools in New York state.³⁰ In our analysis we could demonstrate that there is clearly an overlap between items presented by the PEAT and the analyzed international curricular content, suggesting that those “core items” could be considered mandatory for undergraduate education. A minority of items listed in the PEAT are either not found or rarely found in the curricula, suggesting that such items might not be mandatory for education (see figure).

The emphasis on the range of topics and their order of priorities differed in many UCs from each other and from the PEAT. For example, objectives listed in DIII and DV as part of the PEAT revealed the lowest amount of overlap with the UC. These domains included neuropsychological symptoms (DIII), and the ethics and law section. In the construction of the PEAT, DV (ethics and law) contains 20 objectives ranging from definition of brain death to professional self-reflection regarding attitudes, beliefs, and experiences with death, dying, and bereavement. The first is not mentioned in any palliative medicine UC; the latter is present in more than 75% of the analyzed UC. Over 70% of the UCs did not mention any of the DIII objectives. None of the international UCs used neuropsychological symptoms (PEAT DIII) as a major topic. These two domains (III and V) seemed to be overvalued in the design of the PEAT. On the other hand, almost all UCs did appreciate the symptom set of neuropsychological symptoms as necessary, but they summarized it within general symptom management. This strategy avoids the risk of overstating certain symptoms as being of greater importance and subsequently under-appreciating other symptoms because they do not yet belong to well-accredited medical specialties.

Since undergraduate education on palliative care topics is often delivered in courses not exclusively named “palliative care education,” a mapping tool for medical schools is warranted. In recent studies from Switzerland¹ and the UK,³⁰ detecting ‘hidden’ palliative care topics in the UC has been a major challenge. Such a palliative care education assessment tool should cover the main topics of most undergraduate palliative care education curricula. Development of a new German UC in palliative care and revision of the existing PEAT should be concurrent with this view, and we propose that a revised PEAT would be a valuable tool based on which to standardize the development of this new national curriculum.

In Germany the next steps of the curriculum development process for the mandatory training in palliative care are as follows:

1. A PEAT revised German version will be developed to detect hidden palliative care topics in the UCs of German medical schools. For this purpose the PEAT items noted in 25% or fewer of the international curricula (see figure) will be omitted.

2. Through a Delphi process, the remaining 65 PEAT items will be discussed with experts in the field during a workshop and they will be asked to suggest items not yet mentioned (Delphi round 1).

3. The complete item list will be sent out to other experts with the request to score whether each item should be considered as mandatory for undergraduate education in palliative medicine using a Likert scale (Delphi round 2). Based on this assessment, the PEAT revised German version will be developed.

4. All German medical schools will then be asked to use the instrument in a validation process.

5. The last step of curriculum development will be to develop learning objectives based on the validated PEAT revised German version, a challenge that we are happy to accept.

Limitations

There are clear limitations to our study. Only a relatively small number of UCs were identified. There may well be more that were not identified in this evaluation. The broad variety in the design of the UC is also problematic in the context of cross-comparison. The PEAT has not been developed to analyze curricula from different countries with different medical education systems. For this purpose the PEAT is not validated, but seems to us the only available and suitable instrument for curricula comparison at this time. During the analysis process, it became evident that some objectives of the PEAT are frequently omitted in international UCs. In this situation two interpretations are possible. First, the UCs do not contain all PEAT objectives and therefore should be supplemented by missed PEAT objectives, or second, the PEAT in its current version contains single objectives that might not be mandatory for undergraduate education in palliative care. We believe that the second interpretation of our data is more appropriate, although in the absence of further definitive data, we state this interpretation with caution.

A further drawback is that all UCs were assessed in the same manner, although some UCs clearly stated that they provide only a framework, whereas others provided more extensive material. However, for the purpose of developing a PEAT revised German version and based on the aim to develop a robust German undergraduate palliative care curriculum with clear learning objectives, those drawbacks do not appear to be insurmountable.

Footnotes

Acknowledgments

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Author Disclosure Statement

No competing financial interests exist.

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