Fifth-Year Medical Students' Knowledge of Palliative Care and Their Views on the Subject

Abstract

Background and Objective:

While palliative care is becoming more important in today's health system, the major barrier to improving the quality of palliative care appears to be health professionals' lack of knowledge. The objective of this study is to evaluate medical students' knowledge on palliative care and their views on palliative care in clinical practice.

Methods:

This study was a descriptive, single-center, questionnaire-based survey conducted on fifth-year medical students. Questionnaires were distributed to 250 fifth-year medical students. The standard Palliative Care Knowledge Test was used to assess the level of knowledge in palliative care and a questionnaire was given that included 34 questions about their views on palliative care. The data of the 175 students who answered the questionnaires were evaluated.

Results:

The mean age of the students was 22.7±1.2, and 55.4% of them were male. Approximately 64.6% of the students stated that the education on palliative care was insufficient and 90.3% stated that they did not receive any training on communication skills regarding palliative care patients. Stating that the use of opioids was insufficient in cancer patients were 34.3%, with 54.3% saying that pain management was insufficient. Approximately 61% of them stated that they observed that the primary physicians did not do much and only monitored the disease and were not interested in symptom control, psychosocial support, or rehabilitation. The Palliative Care Knowledge Test results revealed a high percentage of incorrect answers about symptom control.

Conclusions:

It was observed that medical students trained to become tomorrow's physicians had inadequate knowledge on palliative care; the curriculum had a shortfall on this subject; and health professionals did not pay attention to this subject in clinical practice. The results of our study will provide guidance in preparing the curricula of health professionals and in planning the subjects of postgraduate education.

Introduction

The importance of palliative care has only recently begun to be acknowledged in society and among health care professionals, and shortcomings in knowledge and clinical practice have been observed. When the literature is reviewed, it is observed that doctors have insufficient knowledge and training in palliative and end-of-life care.^1–6 Although education programs on medicine and nursing include palliative care and end-of-life care training, the scope of the training in these programs is still inadequate.⁷ Clinical experience in this field is quite limited.^6,8–10 In previous studies conducted on this subject, it has been noted that knowledge and skills can be improved further by pilot training programs on palliative care.^11–14 Nevertheless, accepted programs on palliative care training have not been formed yet. Studies in the literature have so far been conducted rather to evaluate the results of pilot trainings on palliative care.^15–17 In order to assess the level of knowledge, questionnaires prepared by palliative care centers were used in some studies and specific questionnaires were used in others. The Palliative Care Quiz for Nursing is observed to be the most frequently applied test.¹⁸ It was already known that this test has some missing aspects, and the Palliative Care Knowledge Test was developed afterwards to evaluate doctors as well.¹⁹ In Turkey, palliative care training has not reached the desired level in basic training programs of medical faculties. The first officially approved palliative care center with beds in Turkey was opened in our university in 2011. Palliative care has been provided at our university on a multidisciplinary basis since 2005. The Turkish Ministry of Health prepared an action plan for applying palliative care in clinical practice and improving education, which is to be realized by 2015. However, there is no data in Turkey about medical students' knowledge of palliative care and their views on the subject.

The objective of this study is to evaluate medical students' knowledge on palliative care and their views on palliative care in clinical practice.

Materials and Methods

Study setting

This study was a descriptive, single-center, questionnaire-based survey conducted with fifth-year medical students. The total duration of medical education in Turkey is six years. Fifth-year students were chosen for this study, because all clinical rotation is completed by the fifth year and theoretical education is completed in the fifth year. Students carry out active clinical study as interns in the sixth year. Lessons relating to palliative care were added last year to the third- and fourth-year curricula as theoretical lessons. In addition, fourth- and fifth-year students have now the possibility of seeing the palliative care center in our university during their oncology rotation. Our study had been conducted before these educational module modifications were made. Each participant was informed about this study and their written consent was obtained. The questionnaire was distributed before lectures. None of the students received any sort of help while filling in the questionnaire. Only the initials of the respondents were written on the forms and confidentiality was assured.

Data collection

A preliminary questionnaire was filled in by ten graduate students to identify and eliminate bias in the questionnaire design. The questionnaire consisted of two parts. The first part included 34 questions. To prepare these 34 questions in the first section, all the other studies conducted on this subject were examined first. The results obtained from all the published studies were reviewed before preparing these questions. Moreover, since the curriculum may be planned on the basis of the data to be obtained from the survey, this was also taken into consideration. In this part, the questions “What is palliative care?” and “What is the purpose of palliative care?” were open-ended. In order to evaluate the responses to open-ended questions, the written answers in all the questionnaires were first entered in a two-column table by a single analyst. Then, those answers that were similar to each other such as “improving quality of life” and “increasing quality of life” or “symptomatic treatment” and “symptom-reducing treatment” were grouped as a single response by three analysts. In this way, the responses were simplified and similar responses were grouped together. Different responses that were not grouped together were indicated separately. Other questions were answered as “yes-no” and “adequate-inadequate/I have no idea,” which evaluated students' knowledge and views on palliative care and the end-of-life period.

The second part of the questionnaire included the Palliative Care Knowledge Test.¹⁹ Forty questions were used at the stage of developing this test. Then, 20 questions selected from these 40 questions were validated. Since there was no validation and reliability work carried out for this Turkish language test and there was no communication section in this 20-question part, its long version with 40 questions was used. The word “Japanese” used in the questionnaire by the authors who developed the test was replaced by “Turkish.” This test included subdivisions such as philosophy, pain, dyspnea, psychiatric problems, gastrointestinal problems, and communication. The correct and incorrect answers of the questions were defined while the test was prepared.

Statistical analyses

Descriptive statistical methods were used. The demographic data were described with frequency, mean, and standard deviation. The data were analyzed by the χ² and Mann-Whitney U tests, using SPSS 13.0 (SPSS Inc., Chicago, IL). A p value less than 0.05 was considered significant.

Results

Data characteristics

Questionnaires were distributed to 250 fifth-year medical students; 192 questionnaires were returned. Seventeen of them were excluded from the study due to incomplete filling of the query forms.

The mean age of the students (n=175) was 22.7±1.2 and 55.4% of them were male; 62.9% of the students had done oncology rotation, and 61.1% of the students had followed up on terminal stage patients.

Palliative care

When the answers given to the open-ended question “What is palliative care?” was examined, it was observed that 74 students (42.28%) defined it as a treatment for relieving symptoms, 20 students (11.43%) defined it as a treatment for improving quality of life, 10 students (5.71%) defined it as a noncurative treatment for protecting or improving patients' condition, 10 students (5.71%) defined it as a support treatment, and 3 students (1.71%) defined it as a treatment for providing patients with physical and psychological functionality. Seven students (4%) gave the following answers: “making the patient feel less burdened by the terminal disease,” “salvage treatment,” “treatment for making the patient's life easier,” “care given to patients in need of nursing,” “medical and paramedical approach applied to enable patients to spend their remaining time in the most comfortable way,” “treating complications, not the first cause,” and “minimizing patient's disability caused by the disease.” Fifty-one students (29.14%) did not answer this question. To the question “What is the purpose of palliative care?” students (n=134) gave the following answers: relieving symptoms (40%), increasing quality of life (56%), and comforting patients (4%).

Education

Approximately 98.9% of the students stated that they had not received any education on palliative care, 64.6% stated that the education on palliative care was insufficient, and 90.3% stated that they had not received any training on communication skills regarding palliative care patients. Reporting that they considered it difficult to tell someone that he or she is going to die were 55.4%. According to 57.1% of the students, they had not received any training on end-of-life treatment.

Symptoms

Of the students, 69.7% stated that the education that they received on symptom control was insufficient; 34.3% of the students stated that the use of opioids was insufficient in cancer patients, and 54.3% said that pain management was insufficient. Sixty percent believed that symptom control was performed insufficiently.

Approximately 61% of the students observed that the primary physicians did not do much and only monitored the disease and did not pay attention to symptom control, psychosocial support, or rehabilitation.

Knowledge test

The Palliative Care Knowledge Test results are given in Table 1. According to the results of this test, most of the students gave correct answers to the questions about palliative care philosophy. The answers given to the questions about pain, dyspnea, psychiatric problems, and gastrointestinal problem were mostly incorrect or unsure. The answers given to half of the questions about communication were correct.

Table 1.

Palliative Care Knowledge Test Answers (%)

	Student's answers (%)
Questions	True	False	Unsure
Philosophy
Palliative care should only be provided for patients who have no curative treatments available (False)	11.5	78.7	9.8
Palliative care should not be provided along with anticancer treatments (False)	10.9	79.3	9.8
What is important for quality of life varies among individuals (True)	92	5.7	2.3
The patient provided palliative care must accept death (False)	4.6	84.5	10.9
Pain
When a patient with cancer has pain, opioids should be started first (False)	9.8	76.4	13.8
One of the goals of pain management is to get a good night's sleep (True)	94.3	3.4	2.3
When cancer pain is mild, pentazocine should be used more often than an opioid (False)	25.4	11.6	63
When opioids are taken on a regular basis, nonsteroidal antiinflammatory drugs should not be used (False)	14.9	48	37.1
Regular use of an analgesic drug is effective for management of cancer pain (True)	66.5	15.6	17.9
The effect of opioids should decrease when pentazocine or buprenorphine hydrochloride is used together after opioids are used (True)	13.3	22	64.7
Some antidepressant and anticonvulsant medications help relieve cancer pain (True)	82.3	3.4	14.3
Even if breakthrough pain occurs when opioids are taken on a regular basis, the next dose should not be given earlier than scheduled (False)	37.4	25.9	36.8
Long-term use of opioids can often induce addiction (False)	66.5	19.7	13.9
Use of laxatives is effective for preventing opioid-induced constipation (True)	54.3	18.9	26.9
Increase in opioid dosage should be limited because respiratory depression can occur as a side effect (False)	85.6	5.2	9.2
Use of opioids does not influence survival time (True)	64.9	16.7	18.4
Dyspnea
Morphine should be used to relieve dyspnea in cancer patients (True)	22.4	47.7	29.9
When opioids are taken on a regular basis, respiratory depression will be common (False)	39	31.4	29.7
Oxygen saturation levels are correlated with dyspnea (False)	60.2	21.1	18.7
Evaluation of dyspnea should be based on subjective report of patients (True)	39	47.7	13.4
Anticholinertic drugs or scopolamine hydrobromide are effective for alleviating bronchial secretions of dying patients (True)	50.9	4.6	44.5
The only effective way to alleviate bronchial secretions in dying patients is by suctioning (False)	25.6	43	31.4
Psychiatric problems
During the last days of life, drowsiness associated with electrolyte imbalance should decrease patient discomfort (True)	79.1	9.3	11.6
Benzodiazepines should be effective for controlling delirium (True)	68	7.6	24.4
Some dying patients will require continuous sedation to alleviate suffering (True)	73.4	12.1	14.5
Morphine is often a cause of delirium in terminally ill cancer patients (False)	16.8	34.7	48.6
Delirium occurs frequently in patients who are prone to mental symptoms (False)	53.8	11.1	35.1
Gastrointestinal problems
A gastric tube must be inserted to relieve symptoms caused by digestive tract obstruction (False)	56.1	18.5	25.4
At terminal stages of cancer, higher caloric intake is needed compared to early stages (False)	39.9	29.5	30.6
A decrease in oral intake associated with cancer can only be treated with infusion (False)	22.7	51.2	26.2
Even if oral intake is not possible because of digestive tract obstruction, total parenteral nutrition often improves quality of life if performance status is good (True)	83.9	8.6	7.5
There is no route except central venous for patients unable to maintain a peripheral intravenous route (False)	40.4	38	21.6
When patients receive an infusion of 1000 mL or more per day, pleural effusion and ascites tend to worsen (True)	42.2	14.5	43.4
Steroids should improve appetite among patients with advanced cancer (True)	25.6	23.8	50.6
When patients with ileus use metoclopramide, stomach ache and vomiting may worsen (True)	36.2	23.6	40.2
Intravenous infusion will not be effective for alleviating dry mouth in dying patients (True)	36.4	20.2	43.4
Communication
More than 90% of Turkish patients want full disclosure of bad news including estimated prognosis (False)	83.7	5.8	10.5
Communication skill can be learned (True)	94.8	2.3	2.9
Information that patients and families request and the degree to which patients and families take part in decision making may change according to the course of the illness and the condition (True)	85.6	8.6	5.7
Uncertain information should not be given to patient or family because it may cause additional anxiety (False)	83.5	13.5	2.9

Effect of clinical practice

The level of knowledge on pain control was found to be different between students who completed their oncology internship and those who did not, and this difference was in favor of the students who completed their oncology rotation (p<0.05). There was a significant difference between students who did or did not encounter terminal stage patients regarding the sufficiency of the given education, palliative care philosophy, pain control, and views on symptoms; and this difference was in favor of the students who encountered terminal stage patients (p<0.05).

Discussion

This study showed that fifth-year students could define palliative care and understood its philosophy, but they had insufficient knowledge on symptom control in palliative care patients and communication with patients in need of palliative care. The students themselves also believed that palliative care training and their knowledge on symptom control were insufficient.

Most of the students in our study stated that they had not received any training on palliative care and communication skills. Since the awareness of palliative care has only begun to increase recently in Turkey, palliative care lectures have recently begun to be included in the curricula. Lessons relating to palliative care were added last year to the third- and fourth-year curricula as theoretical lessons. In addition, fourth- and fifth-year students have now the possibility of seeing the palliative care center in our university during their oncology rotation. Our study was conducted before these educational module modifications were made. However, a palliative care course in the third and fourth grades has been added to the curriculum as a 45-minute theoretical lesson given only once a year. In addition, since not every student in the fourth and fifth grades is placed in an oncology rotation, not every student has the opportunity to work in the palliative care unit. Therefore, a curriculum prepared this way does not provide students with further knowledge/experience beyond having a general opinion about palliative care. It is evident that the duration and teaching method of palliative care lessons/courses should be changed in the curricula for students to be prepared in the future, and this opinion is also supported in the literature. However, education is generally given as traditional classroom-based medical training, and this is reported to be inadequate for the task.²⁰ Such small modifications could be made in our faculty in consideration of the study results, but unfortunately palliative care training is not included in the educational modules of all medical faculties. Until recently, palliative care training has not become mandatory in medical education even in developed countries;^2,21,22 85% of the students in British medical faculties and only 25% of those in the United States stated that they underwent clinical rotation on end-of-life care.²³ Sullivan and colleagues reported in their study that less than 18% of the students received education on end-of-life care.²⁴ In our study, 57.1% of the students stated that they had not received training on end-of-life care. In a study conducted in the United States, 39% of the medical students reported that they experienced problems in talking about death and about their views on this subject.²⁴ In our study, 55.4% of the students thought that telling someone about death would be difficult. Medical students may have given this answer for the sake of being realistic through empathy, such as in the first question of the communication section. Similarly, this may have resulted from their lack of experience about palliative care. Students are likely to give a more factual answer to this question after they receive adequate palliative care training and have more experience in palliative care. The answers given to the questions about symptom control were observed to be better among students who completed their oncology internship or who followed up on terminal stage patients compared to students who never encountered this group of patients. In the study conducted by Anderson and colleagues, students who took care of terminal stage patients had more positive attitudes and higher knowledge scores than those who did not.²⁵ These results show the importance of following up on palliative care patients in clinical practice in terms of acquiring education and learning on the subject.

It has been demonstrated in some studies that health care professionals are given insufficient education on the care of patients with terminal disease and their families.^24,26 In our study, when the answers to the questions about symptom control were examined in both the questionnaire and student feedback, the education received by the students was found to be insufficient. This result is even more distinctive regarding pain control. In a study conducted in the United States, the rate of correct answers given to the questions about pain assessment and treatment was 46% among first-year interns and 57% among resident doctors.²⁷ According to the results obtained by Fraser and colleagues, only 50% of medical students considered themselves sufficient in end-of-life symptom control.²⁸ Moreover, the students included in our study believed that symptom control in patients was also insufficient. Physical and psychological support treatments were reported to be inadequate in palliative care patients.²⁹ This result demonstrates the importance of both undergraduate and postgraduate trainings in terms of clinical practice.

Our study is the first study conducted in Turkey that researched medical students' knowledge of palliative care and their views on the subject. Our study had some limitations; the data obtained from a single university cannot be generalized for the whole country. Our hospital includes a palliative care center and, therefore, we can expect students to be more aware and informed on this subject. On the other hand, obtaining these results requires us to be even more sensitive toward palliative care training in other universities. The response rate was also considerably high. Students less interested in palliative care may have not responded at all. This may make one think that the knowledge level is even lower in reality. Consequently, it was found that fifth-year medical students, who are tomorrow's doctors, had insufficient knowledge on symptom control in palliative care patients. Considering the fact that the level of knowledge of those students who follow up on palliative care patients during their education can be improved, palliative care training modules should be included in undergraduate medical education. We believe that our study results will provide guidance for health care professionals in Turkey in preparing undergraduate and postgraduate education programs. Similarly, the education committees of the Ministry of Health may also benefit from our results.

Footnotes

Acknowledgments

This study was presented in a poster format at the 13th World Congress of Psycho-Oncology, which was held in Antalya, Turkey, October 16–20, 2011.

Author Disclosure Statement

No competing financial interests exist.

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