Educational Issues for Specific Endof Life Domains

PAIN EDUCATION. Pain must be controlled before physicians can assist patients with the myriad of physical, psychological, and spiritual problems at end-of-life. Yet, physicians frequently fail to apply accepted standards of care for acute or chronic pain management. Moreover, it is clear that despite a multitude of clinical guidelines, position papers, workshops, lectures, grand rounds, journal articles, and book chapters written about pain management, clinical practice is still far from ideal.

The primary reason that conventional education formats fail to translate into a change in clinical practice is that physicians harbor a host of attitudes about pain and pain management that inhibit the appropriate application of knowledge and skills. These attitudes fall into two broad categories. First are physician attitudes about pain that reflect societal views about the meaning of pain and pain treatment. Second are the fears and myths about opioid analgesics. These include fears of addiction, respiratory depression, and regulatory scrutiny, along with the secondary consequences of these fears—malpractice claims, professional sanctions, loss of practice privileges, and personal guilt about potential culpability for causing death.

In addition to attitudes, deficits in pain knowledge and skills are widespread. These include how to conduct a pain assessment, clinical pharmacology of analgesic medications, use of non-drug treatments, and skills in patient education and counseling. Educational techniques and results from various pain education programs have been reported; key findings from these include the following principles: pain education must include attention to attitudinal issues along with knowledge and skills; pain education must be longitudinal across all years of medical training; and pain education must be coupled to other elements of institutional change, such as quality monitoring, team building with non-physicians, development of routine assessment, and documentation and analgesic standards development.

ETHICS, LAW AND COMMUNICATION SKILLS EDUCATION. There is considerable content overlap between ethics and communication skills. For example, to effectively care for patients, trainees need to understand both the ethical and legal framework of advance directives and the communication skills necessary to discuss these with patients. Similarly, trainees need to understand the ethical and legal background to make decisions about treatment withdrawal and to acquire the skills to discuss these issues with patients and families.

There is a rich literature on educational methods and outcomes in ethics and communication skills education. Although ethics is generally considered a preclinical course in medical school, it is advisable that training in ethics be incorporated throughout medical school, residency, and fellowship training. As the level of professional responsibility increases with each year of training, such responsibility imposes demands on the trainee to make increasingly complex and ethically challenging decisions. Such decisions often strain the trainee's personal understanding of professionalism and altruism and thus merit dedicated time for self-reflection and mentoring. Although both ethics and communication skill training require attention to attitudes and knowledge deficits, communication skill training requires special and dedicated attention to the acquisition and demonstration of specific skills. Notably, trainees must be able to demonstrate their ability to give bad news and discuss treatment goals, treatment withdrawal, and issues surrounding hospice and palliative care empathetically and professionally.

CLINICAL TRAINING EXPERIENCES. Hospital-based palliative care teams are a valuable venue for clinical education in end-of-life care. Trainees, both physicians and nurses, can learn how to work within a multidisciplinary group and experience a collaborative process with the educational focus enlarged to include the physical, psychological, social, and spiritual dimensions of care. Since 1992 many medical schools and residency programs have established successful clinical experiences in hospice and palliative care at acute care hospitals, hospice residence facilities, and at home.

PERSONAL AWARENESS TRAINING. Very few health professionals have had formal training in how to deal with the emotions that arise when caring for patients with progressive fatal illness. Undergraduate course, residency, and fellowship directors have a number of options that can help trainees gain the needed personal awareness including support groups, family of origin group discussions, meaningful experiences discussion, personal awareness groups, literature in medicine discussion groups, and psychosocial morbidity and mortality conferences.

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