Self-confidence and knowledge of German ICU physicians in palliative care – a multicentre prospective study

While intensive care medicine is traditionally committed to treat life-threatening organ dysfunction and to restore the patients’ health, palliative care focuses on quality of life in patients suffering from life-limiting illnesses at an advanced stage and also in deceasing patients and their relatives. The symptoms palliative and critical care patients suffer from widely overlap (e.g. pain, dyspnoea, delirium, disorientation, anxiety, nausea and vomiting), each of them requiring a specific treatment [1]. The need for palliative care on ICUs has increasingly been acknowledged in the past decade [2]. When palliative care competences are to be implemented in daily care, it is of importance to consider whether the policy of the respective ICU is based on an integrative model or a consultant model [3]. In an integrative model, ICU physicians have to possess palliative care competences; in contrast, in a consultant model these competencies are located outside the ICU, but ICU physicians have to initiate the referral following specific algorithms [3, 4]. Recently, it has been shown that integrating palliative care physicians into critical care significantly decreased ICU length of stay for referred patients without increasing mortality [5]. Nevertheless, another recent study identified a lack of competence in palliative care to contribute to futile life sustaining treatment in intensive care medicine [6].

In 2004, the German government recognized the need for improved palliative care [7]. Consecutively, in 2009, the Medical Licensure Act in Germany was adapted to improve palliative care and since then, palliative care is introduced for the medical students as a cross-sectional subject with obligatory examination [8]. Based on this novelty, the first students were licensed in 2014 [9]. But physicians currently working on intensive care units (ICUs) did not benefit from a curriculum on palliative medicine so far. However, there may be additional factors which may positively impact their self-confidence and knowledge related to palliative care such as work experience, [10, 11] additional certifications in either pain or palliative medicine, their medical background (specialty) [10, 11] or, possibly, gender [10‐13]. Standardized questionnaires for this setting do not exist.

Therefore, this study aimed to investigate the current ICU physicians’ self-confidence and knowledge related to palliative care in an exploratory manner. For both, self-confidence and knowledge, a questionnaire was developed. Then, we analysed whether the results were associated with the participants’ additional certifications in either pain or palliative medicine, the overall amount of time they worked on ICU, their gender and professional specialties. Furthermore, results from the questionnaires’ item analysis are provided. Finally, we report the correlation between self-confidence and knowledge.

There were two themes (basics in palliative care and euthanasia) with which more than half of the participants felt not or rather not confident (Table 2). Although weak, self-confidence showed a significant correlation with the results of knowledge testing in female but not in male. Similar results have been found in other studies where female participants provided lower self-assessments although they performed equivalently [12] or even better [13] than their male colleagues. Another study assessed self-rated knowledge in end-of-life care and did not find differences between women and men [10]. From the investigated independent variables only the presence of a CPoP and work experience was associated positively with the participants’ self-confidence. According to the results of the regression analysis, the effect of work experience, however, is very weak compared to the impact of the CPoP.

Importantly, knowledge is not competence. The assessment of conscious knowledge, corresponding to Kirkpatrick’s level II, does not necessarily predict a physicians’ interplay with their clinical environment (Kirkpatrick’s level IV) [20]. That is, competence may result from experience-based intuitive and unconscious behaviour [21]. Therefore, MCQ results, although alarming, do not allow for direct conclusions on the participants’ ability to provide accurate palliative care in their respective work environment. In all investigated hospitals the ICU physicians had the opportunity to consult a palliative care team. Finally, as 1) MCQs serve for knowledge testing but not necessarily for the assessment of competence and 2) the frequency with which a palliative care team was consulted was not assessed, we cannot state the quality of palliative care in this sample.

Work experience was associated with self-confidence but not with knowledge (Table 3). We suggest that more experienced ICU physicians may have competence that is not reflected by the knowledge or tend to overestimate their abilities. Such an additional qualification was present in only 10% of all participants, increasing to 29% in senior consultants. This implies that less than one third of the leading ICU personnel had a CPoP. A similar gap has been described for communication: two studies reported differences between the physicians’ rating of their own communication skills compared to the patients’ perception of the physicians’ communication skills [22, 23].

There is hardly any literature evaluating knowledge and self-confidence related to palliative care. In a study involving physicians and nurses in an ICU setting, the need for improvement was found mainly for spiritual support for families, emotional support for clinicians, and education about palliative care [18]. Not surprisingly, another study found palliative care specialists and geriatrists to know more about the laws regulating the withholding/withdrawing life-sustaining treatment than other specialties [24]. In internal medicine residents, only clinical experience was found to be correlated positively to self-confidence and the authors conclude that increasing the experience in treating patients in end-of-life situations with appropriate supervision may result in improved competence [25]. Haematology/oncology fellows rated palliative care education within this fellowship to be inferior to general oncology and the authors identified the themes pain management, identifying the patients’ psychosocial needs and communication as promising goals for training [26]. Elsewhere, data are provided about palliative care knowledge and the impact of learning interventions for students [27] and nurses [28, 29] but the results cannot be transferred to ICU physicians.

Taken together, the studies related to palliative care do not consistently identify particular points of improvement. An important first step for ICU physicians is the transition from curative to palliative care in the individual patient [30]. This often proves to be rather difficult when faced with families’ resistance towards therapy ptions other than curative as well as their concerns physicians might give up on their relative [31]. Numerical rating scales, the Behaviour Pain Scale and the Respiratory Distress Observation Scale help to recognize and assess typical symptoms of the dying patient quickly [32]. Our data suggest that, beyond the implementation of rating scales, additional qualifications in palliative care beyond the regular curricula in ICU medicine enhance knowledge on one hand, and self-confidence on the other. In Germany, qualification in pain medicine requires a physician to complete an 80-h course, to have worked in pain medicine 1 year full-time with expert supervision and to have finished residency. To be certified in palliative care, a physician has to complete a 40-h course, and must have either worked 1 year in palliative care or, alternatively, complete a 120 h of case conferences and provide 20 extensive case reports, while having worked in direct patient care for at least 2 years. The results suggest that these qualifications are useful to enhance palliative care in the integrative model. An important next step is to investigate whether the introduction of the subject palliative care into the medical studies in Germany will influence self-confidence and knowledge once these students work as residents on ICUs.

Although there are limitations in the use of our questionnaire, it appears that, with respect to palliative care, ICU Physicians’ self-confidence is not related to their knowledge. An additional certificate in either pain or palliative medicine was positively correlated to both self-confidence and knowledge. However, only a minority of the participants were qualified through such a certificate. Future research should identify topics for goal-directed interventions to strengthen competence in palliative care in the ICU setting.