Palliative care education in the undergraduate medical curricula: students’ views on the importance of, their confidence in, and knowledge of palliative care

Due to the aging population and growing number of people with chronic diseases, such as heart failure, Chronic Obstructive Pulmonary Disease (COPD), and dementia [1, 2] and the higher survival rate for diseases like cancer, the number of patients needing palliative care due to life-threatening illness is increasing. The World Health Organization (WHO) defines palliative care as ‘an approach that improves the quality of life of patients and their families who are facing problems associated with life-threatening illness through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual [3]‘. Providing palliative care is challenging because of the multidimensional (physical, psychological, social and spiritual) and multidisciplinary aspects involved. Physicians working in nearly all specialties and many care settings regularly have to provide palliative care to the chronically and terminally ill. They should, therefore, acquire in their training the necessary attitudes, knowledge, and skills to do so [4].

The World Health Organization [5] and the European Association for Palliative Care [6] (EAPC) underline the importance of palliative care education. Lack of palliative care education in the undergraduate medical curricula throughout Europe is considered as one of the most important barriers in the integration of palliative care in health care systems [7]. Several studies have reported that medical students are given inadequate education and training in palliative care [8‐10] and many junior doctors across different countries (for example: The United States [11]; Brazil [12]; Germany [13] and Turkey [14]) do not feel well prepared. The majority of medical graduates reported that they felt uncertain about providing palliative care [13]. They lack knowledge of palliative care [13], especially on the pain and symptom control aspects [13]. However, research shows that an integrated palliative care curriculum leads to increasing knowledge [15], and physicians with special education in palliative medicine make less aggressive decisions in end-of-life care, as to withdraw life-prolonging therapies, indicating the importance of palliative care education [16].

Currently, in the Netherlands, undergraduate medical curricula spend little time on palliative care. An EAPC expert committee evaluated the degree to which palliative care education was covered in undergraduate medical curricula in Europe and demonstrated that the Netherlands belongs to the five European countries that scored the lowest [17]. Dutch medical education tends to disregard the competencies required to decide whether or not to treat [18]. A recent study showed that End-of-Life Care education is insufficiently mentioned in the Dutch national blueprint for undergraduate medical curricula and is not fully integrated in compulsory medical curricula at the universities [19]. Another study [20] also demonstrated that, from the perception of undergraduate medical students, more attention should be paid to end-of-life care. Nevertheless, there is an increased interest in palliative care teaching [4, 21]. In order to develop palliative care training that is aligned with the perspectives and needs of undergraduate medical students, it is important to understand how medical students relate to palliative care and what their learning needs are. The perspectives of students on palliative care, as defined by the WHO, are currently unknown and need further research. The objective of this study is to investigate undergraduate students’ views on the importance of education in palliative care, their opinion of the education they have received, and their (self-reported) confidence in and knowledge of palliative care.

In total 222 (response rate 38%) final-year students from four Dutch medical universities participated. The mean age was 24.9 years (SD = 1.79) and 160 students (72.1%) were female.

This study demonstrates that medical students view palliative care as an important topic to be covered in their undergraduate medical education. However, according to the surveyed students, most aspects of palliative care are not covered properly. They do not feel confident in providing palliative care and lack the necessary knowledge. These results are in line with to the growing body of research showing that medical students are not adequately prepared to provide palliative care [8, 11‐13]. The findings of our study are in line with results reported in various countries like the United States [11] and Germany [13] .

Second, the students indicate that they lack education on the psychosocial and spiritual needs of palliative care patients, which again may explain why they lack confidence in this. This is in line with the research of Best et al. [25] and Ellis et al [26] who found that doctors only rarely raise spiritual aspects of care, although many patients would be interested in discussing issues around spirituality in the medical consultation. Best et al [27] found that the underlying confusion regarding the differences between religion and spirituality is one of the important contributors to the reluctance of doctors to discuss spirituality with patients. Medical curricula are mainly based on the bio-psycho-social model [28], and shifting towards a biopsychosocial-spiritual model could lead to more holistic and better patient care.

Third, students responded positively on the topic of ethics concerned with the end of life care and they indicated that ethical aspects were properly covered. This finding is further supported by the results of the knowledge test, where students scored remarkably high on the ethics question. This result is line with research of Hesselink et al [20] who found that medical students perceived the content and quality of end-of-life- care moderate-to-good. However, Thurn and Anneser [29] reported that German medical students experience moral distress frequently in end-of-life care and emphasize the importance of empowering students by means of training to address their moral concerns. Differences between our findings in which ethics were more positively rated, could be explained by cultural differences or by differences in training.

Although we did not formulate a research question about the relation between the different variables, we correlated the measures to check how they relate to each other. This resulted in a positive correlation between self-confidence and knowledge (R = 0.22; P = 0.000) and between self-confidence and the degree to which relevant topics were covered in the curriculum (R = 0.40, P = 0.006); which is in line with our expectations; i.e. a better score on knowledge is positively related to self-confidence and a higher score on topics covered during training is also positively related to self-confidence.

Several issues should be taken into account when interpreting the results of this study. This is a multi-center study and the four participating universities are spread geographically throughout the Netherlands. The demographic characteristics of the participating students are comparable to those of the population of Dutch undergraduate medical students. The questionnaire consists of three different components: [1] perceived importance, [2] degree to which a given topic is covered in the curriculum and [3] the degree to which the student feels competent/confident. Put together, the results offer a broad perspective on students’ views and current learning needs.

The study also has some limitations. Just like in the study by Weber et al [13], the response rate was relatively low, which could imply that only motivated students responded [30]. As a consequence, the importance of palliative care education could be overrated. The questionnaire was based on an existing questionnaire in order to connect with the literature. The disadvantage was that this questionnaire pays unequal attention to the different dimensions of palliative care and focuses more on cancer than on other palliative conditions. Another limitation of the study is that only the knowledge section of the used instrument makes use of a formerly validated instrument. The other two sections and the translation of the knowledge section were not revalidated.

This study determined which aspects of palliative care are important to medical students. The results have important implications for practice and research. Universities can use these results to anticipate the learning needs of the students and improve their education programs to better prepare students for a care context in which the need for palliative care will increase due to the expanding aging population and the growing number of people with chronic diseases. Thereby, this study offers an important first step in the development of palliative care education in undergraduate medical curricula. To develop a full picture of what should be covered in the medical curricula will require additional studies with stakeholders other than students involved.

This study reveals that medical students view palliative care as an important subject that should be addressed properly in their medical education, especially the aspects of patient-focused work and communication. The respondents reported limited confidence in providing palliative care. The four medical schools involved in this study address many palliative care topics to a limited extent in their curricula. The findings will be of interest to all those concerned with the development of palliative care education.