Introduction of palliative care into undergraduate medical and nursing education in India: A critical evaluation
AIM: To introduce palliative care into undergraduate medical and nursing education, and to ascertain if such training improved students' knowledge of palliative care. MATERIALS AND METHODS: Third year nursing students and fourth year medical students at the St John's National Academy of Medical Sciences, Bangalore had five weekly lectures in palliative care. A 20 item questionnaire was administered to 4th year medical students before and after the educational intervention, and again after one year. The same questionnaire was administered to the control group of final year medical students. The questionnaire for 3rd and 4th year nursing students had 15 questions. RESULTS: The mean scores for medical students was 9.08 (S.D 2.5) in the pretest, 10.43 (S.D 1.63) in post-test I, and 8.43 (SD 1.36) in post test 2. The control group scored 8.36 (SD 2.52). The mean scores for nursing students was 8.7 (S.D 1.8) in the pretest, 10.73 (SD 2.63) in post test 1 and 8.23 (SD 4.1) in post test 2. The control group scored 8.13 (SD 2.39). CONCLUSION: There was no lasting improvement in knowledge scores in both groups of students. Inclusion of palliative care in the undergraduate teaching of medical and nursing students in India is feasible, but thought needs to be given to the curriculum content, teaching methods and evaluation techniques.
Keywords: Medical education, nursing education, palliative care
Palliative care is now included in undergraduate medical and nursing training in many western countries. Although palliative care came to India nearly two decades ago, till recently no medical or nursing college had palliative care teaching for undergraduate students. The introduction of palliative care into undergraduate medical and nursing training is a necessary step in the development of a formal system of education and registration of palliative care in India. St.John's National Academy of Health Sciences first introduced palliative care into undergraduate medical and nursing curriculum in 2001.This paper is an evaluation of the first year of our programme.
Palliative care classes were introduced for third year nursing students and fourth year medical students. The course comprised of five weekly lectures. [Table - 1] The effect of the teaching was assessed using pre and post test questionnaires. There were 20 questions in the medical student questionnaire, and 15 in the nursing questionnaire. (Appendix 1) Post test 1 was administered immediately after completion of the course, and post test 2 a year later. The scores of post test 2 were compared with post test 1 and also with the scores of the control group of final year students.
Data was analysed using SPSS. Mean and standard deviations were calculated for all the groups. Further comparisons were made using the one way ANOVA followed by Tukey's post-hoc test. Significance was set at 0.05.
A total of 39 students underwent the course. 36 students attended the pretest, 35 students attended both post tests. The control group had 45 students.
The average mark obtained in the pre test for the entire class was 9.08 ± 2.5. This rose to 10.43 ± 1.63 in the post-test I (P<0.05). Post test 2 scores, however were not significantly different from the pretest, (8.43 ± 1.36 Vs 9.08 ± 2.5.), indicating that students did not retain the information after one year. Nor was there a significant difference between the pretest and the scores of final year medical students who served as controls (8.43 ± 1.36 Vs.8.36 ± 2.52) indicating that students did not learn these aspects of palliative care from other postings in their final year. [Table - 1]
Thirty students underwent the course and took all three tests. The control group had 32 students. There was a small improvement in knowledge scores immediately after the lectures. (from 8.7 + 8 to 10.73 ± 2.63), but this was not sustained in post test 2.(8.70 ± 1.80 in pretest Vs. 8.23 ± 4.10 in post test II). Here again there was no significant difference between post test II and the marks of the control group. (8.23 ± 4.10 Vs. 8.13 ± 2.39) [Table - 2]
The World Health Organization has called for training institutions to make palliative care compulsory in courses leading to a basic professional qualification. A survey of European physicians found that while 50% of British doctors felt adequately skilled in the care of the dying, fewer than 25% of doctors in other European countries felt the same. (Herzler, 2003)
St. John's National Academy of Medical Sciences is the first medical college in India to introduce palliative care into the medical and nursing curriculum. This is a significant milestone for palliative care in this country, and an important learning opportunity. Our results challenge us to look critically at the content of our curriculum, the teaching methods used and the evaluation tools.
The following domains have been suggested for palliative care education:
Our curriculum heavily emphasized symptom control. Formal teaching of pain and symptom control is important. Finlay found that despite published information on pain control in terminal illness, many house officers did not know the difference between acute and chronic pain, and were not aware of the basic facts concerning use of morphine in terminal illness. Weissman states that a pain education program should be longitudinal, and include a mix of teaching methods. Sloan et al used an objective structured performance based technique to educate family practitioners in pain assessment.
While symptom control is important, it cannot be the only component of a palliative care curriculum. Patient centred communication, ethical issues, decision making at the end of life, whole person care and interdisciplinary work are important and can have a lasting impact on future medical practice.
These aspects of palliative care need not be taught in isolation and should ideally be integrated into the entire curriculum. In some medical schools in the United Kingdom palliative care teaching is integrated into learning in other areas. This helps students apply their palliative care learning to other contexts. (Field and Bee Wee, 2002)
At St. John's, Bangalore students are taught medical ethics through their four and a half years of medical school. Communication skills were taught in the palliative care curriculum. The lecture format is not the best method for influencing palliative care skills and attitudes. Demonstration and mentoring are important, as are opportunities to apply learned knowledge through role-plays and reflective discussions.
Small group discussion of real case-histories are an excellent teaching tool to integrate symptom management, ethical decision making and interdisciplinary teamwork. Charlton, Dovey and Mizushima found in their survey of medical students from the United Kingdom, New Zealand and Japan that students preferred multidisciplinary teaching with the input of physicians, psychiatrists, clergy, and family physicians.
The acquisition of new knowledge is facilitated by good role models. Actual clinical practice is often the best resource for such guided learning. This can be in the specialized environment of a hospice or within a hospital environment. Williamson et al describe a four day programme where students work with palliative care patients, families and hospice staff. In addition they have small group learning, lectures, case presentations and ethical issues. Hospices and medical schools in India could similarly collaborate to provide culturally relevant hands on experience.
Liao et al included palliative care into an internal medicine residency where trainees provided palliative care services to terminally ill patients till death. The latter technique is better applied to postgraduate programmes.
For teaching programmes to remain relevant, evaluation methods are essential. Our pretest and post test questionnaires measured knowledge, but not skills or attitudes. We do not know if this first introduction to palliative care had any impact on attitudes to terminally ill. The slight difference in knowledge scores we found in the immediate post test could even be a test retest bias as the same questionnaire was used. There was no lasting improvement in post test 2. In an education system that is heavily examination oriented, the inclusion of palliative care in student evaluation may promote retention of knowledge, but it is uncertain how much this will impact on practice.
Other studies have reported difficulties in measuring improvement after teaching programmes. In Liao's study, knowledge levels were high at baseline and did not improve significantly. Williamson used a detailed pre and post test to measure knowledge, attitudes and barriers to palliative care. Students, however, requested a shorter evaluation method.
We summarize with Weissman's suggestions for planning future palliative care education:
'Education formats to assess attitudes and values (e.g the meaning to the doctor of treatment withdrawal) are best assessed in small group and/ or one to one settings (e.g. mentorship). Topics that involve specific facts (e.g. use of antiemetics) can be taught in a lecture format or via self study guides reinforced by case discussions. Teaching of end of life skills (e.g conducting a spiritual assessment) is best done by role modelling followed by a chance to practice via role playing and/ or by actual performance under direct observation with immediate feedback. Experiential opportunities (e.g visits to home hospice patients) are an invaluable educational tool to reinforce appropriate attitudes, knowledge and skills.'
Questions common to medical and nursing students
1. What is palliative care?
a. Treatment of cancer patients
b. A type of curative treatment
c. Active total care of patients and families when the disease is no longer responsive to curative treatment.
d. It is only symptom relief
e. All of the above.
2. Palliative care is
a. patient centered
b. disease focused
3. The primary aim of palliative care is
a. to prolong life
b. to delay death
c. mercy killing
d. to make life as comfortable and as meaningful as possible
e. all of the above.
4. Quality of life
a. what a person says it is
b. relates to an individual's subjective satisfaction with life
c. influenced by all dimensions of personhood (physical, psychological, social & spiritual)
d. good when aspirations of an individual are matched and fulfilled by present experience
e. all are correct.
5. WHO analgesic ladder for cancer pain has
a. 2 steps
b. 3 steps
c. 4 steps
d. 5 steps
e. 6 steps
6. Which of the following is not a weak opioid
7. Morphine in cancer pain
a. causes respiratory depression. So it should be avoided
b. causes addiction. So should be avoided
c. does not cause addiction or respiratory depression if titrated against pain
d. more potent than diamorphine
e. a & b.
8. Anorexia in cancer patients
a. should be treated with appetite stimulants
b. should be treated with corticosteroids
c. helping the patient and family to accept and adjust should be the focus of management
d. it is better to neglect that because we can't do anything
e. balanced nutritious food can prevent that.
9. Opioid induced constipation
a. difficult to manage. So change over to another analgesic
b. bulk forming drugs are the best option
c. stimulant laxative is the best option
d. osmotic laxative is the drug of choice
e. any of the laxatives can be used.
10. In denial, professional intervention needed, if
a. denial persists and interferes with acceptance of treatment
b. interferes with planning for the future
c. interferes with interpersonal relationships
d. any of the above
e. denial doesn't need professional intervention because it increases hope.
11. If oral route cannot be used which is the preferred route for prolonged drug administration (e.g. morphine for cancer pain)?
12. Breaking bad news
a. The truth should be revealed to patient irrespective of whether the patient wishes or not.
b. If the patient indicates directly or indirectly that he does not wish to regard his illness fatal, we should not force the truth on him.
c. If the relatives do not wish and the patient wishes to know the truth, we should never reveal it to the patient.
d. Revealing the truth always kills hopes and increases anxiety, so we should never do that.
e. It is helpful to give false hopes because hope increases chances of cure. Hence it is better always not to reveal the diagnosis to the patient.
Questions for student nurses
13. A nursing diagnosis represents the
a. proposed plan of care
b. assessment of patient data
c. actual nursing interventions
d. patient's health problems
14. The effectiveness of nurse - patient communication is best validated by
a. client's feedback
b. health team conference
c. patient's physiologic adaptation
d. medical assessment
e. improvement in health.
15. Treatment of first choice for lymphoedema
Questions for medical students
13. Pseudo obstruction of intestine is common in
a. Ca ovary
b. Ca breast
c. Ca stomach
d. Ca bladder
e. Endometrial carcinoma.
14. Paracetamol is
a. centrally acting
b. peripherally acting
c. anti inflammatory
d. a & b
e. a & c.
15. Which of the following causes irreversible platelet dysfunction?
16. Antiemetic of choice in chemotherapy induced vomiting
17. How do opiods reduce dyspnoea?
a. By acting at the peripheral oxygen sensitive chemo receptor
b. By acting at the carbon dioxide sensitive medullary respiratory centre
c. By decreasing the hypoxic respiratory drive
d. All of the above
e. None of the above.
18. What type of sleep disturbance is most commonly associated with depression?
a. Early morning wakening
b. Repeated awakening
d. Difficulty initiating sleep
e. Excessive sleep.
19. The cardinal principles of medical ethics are
a. respect for patient autonomy (patient's choice)
b. beneficence (do good)
c. nonmaleficence (minimize harm)
d. justice (fair use of available resources)
e. all of the above.
20. Most common cause of diarrhoea in palliative medicine is
b. faecal incontinence
c. radiation diarrhoea
d. imbalance of laxative therapy
e. carcinoid syndrome.
[Table - 1], [Table - 2]